APEX: Neuro - Spinal Cord, APEX: Neuro - Brain, APEX: Regional UE, Unit 8 Regional Flashcards (Lower Extremity) Apex, Upper extremity blocks, Lower Extremity Regional Apex, APEX Regional Flashcards (Upper Extremity), APEX Regional Flashcards (Neuraxi...

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Systemic lupus affect nearly every organ system, most of the consequences are the direct result of what?

Direct result of antibody induced vasculitis and tissue destruction

What may the patient feel with a caudal block setting up?

Fullness in sacrum (normal response)

(2) contraindications for hypokalemic periodic paralysis?

Furosemide Glucose infusion

Calculate expected PAO2 when the PaCO2= 80mmHg, FiO2= 28%, and A-a gradient is 35

PAO2 = (FiO2 x (Pb - PH20) - (PaCO2/RQ) 0.28 x(760-47) - (80/0.8) 200-100 = 100mmHg 100mmHg - 35(A-a gradient) = 65mmHg

Factors that increase risk of TNS

Lidocaine, lithotomy position, ambulatory surgery, knee arthroscopy

*Lipophilic* Opioids: Nausea + vomiting

Lower incidence

Rank opthalmic anesthetic technique according to the amount of pain caused by the procedure(lowest to highest) (retrobulbar, peribulbar, topical, sub-tenon)

Lowest-topical subtenon, peribulbar, retrobulbar-highest

The *psoas compartment* contains the ______________ plexus within a sheath.

Lumbar

The psoas compartment contains the ______________ plexus within a sheath.

Lumbar

Treatment of Guillain-Barre: What does not improve GB?

Plasmapheresis and/or IV IgG Steroids and interferon (they do work for multiple sclerosis)

Ligamentum flavum

Run the length of the spinal canal To Form dorsolateral margins of epidural space thickest in the lumbar region

Supraspinous ligament

Runs most of the length of the spine and joins tips of the spinous process

myasthenia gravis and pregnancy

Symptoms get worse (30% of pts) and antibodies can cross placenta - baby may need airway support after delivery and weakness may last 2-4 weeks.

Absent seizure (petit mal)

Temporary loss of awareness -more common in children

Akinetic seizure

Temporary loss of consciousness and postural tone More common in children

What places does rheumatoid arthritis in the airway

Temporomandibular joint - mouth opening Cricoarytenoid joints - decreased diameter of glottic opening Cervical Spine - Atlanto-occipital subluxation

Cerebral autoregulation definition -Formula for cerebral blood flow

The brains ability to maintain a constant cerebral blood flow over a wide range of mean arterial blood pressures CBF = Cerebral perfusion pressure/Cerebral vascular resistance -Benefit: ensures steady supply of O2 even with blood pressure fluctuations

What is used to monitor for the development of vasospasm?

Transcranial Doppler exams

Describe the relationship of the terminal branches relative to the axillary artery

The axillary block targets 4 terminal branches of the BP as they course distally w/ the axillary a. and axillary v. along the humerus from the apex of the axilla - musculocutaneous n is anterior + lateral - median n. is anterior and medial - radial n. is posterior and lateral - ulnar n. is posterior and medial

Which muscles surround the neurovascular bundle in regards to an axillary block?

The biceps brachii (lateral and superficial), the coracobrachialis (lateral and deep), and the triceps brachii (medial and posterior).

What is cerebral salt-wasting syndrome? How do you treat it?

The brain releases natriuretic peptide, leading to volume contraction, hyponatremia, and sodium wasting by the kidney Treat with isotonic crystalloids *contrast SIADH is caused by euvolemia or hypervolemia and is treated by fluid restriction

Identify the area of defection that causes malignant hyperthermia

The defective ryanodine receptor (RyR1) instructs the sarcoplasmic reticulum to release excessive amount of calcium.

What are used as landmarks for blocks?

Traditional nerve block techniques are based on the ability to palpate muscles, bones, and pulses.

What are the 4 major side effects of neuraxial opioids?

1. Pruritus (most common) 2. Resp depression (hydrophilic drugs worse d/t rostral spread) 3. Urinary retention 4. N/V

Hypobaric

lower density than CSF - rises

Ropivacaine onset, anesthesia, and analgesia

onset 15-30 min, anesthesia duration 5-10 hrs, analgesia duration 16-18 hrs

What does a wake up test, test for?

paraplegia This has been replaced by MEP & SSEP

Third order neuron (Anterolateral)

pass through the internal capsule and advance toward the somatosensory cortex in the postcentral gyrus in the parietal lobe Most pain fibers synapse in the RAS and then connect to the thalamus

Third order neuron (Dorsal)

pass through the internal capsule and advance towards the somatosensory cortex in the postcentral gyrus in the parietal lobe

Sign of pneumo

patient coughs or complains of pain at needle insertion

Transient Neurologic Symptoms (TNS) cause

patient positioning stretching of the sciatic nerve myofascial strain muscle spasm

The obturator n. is prone to injury during extensive _________________ surgery.

pelvic

Anesthetic considerations for AVM include: AVMs are more common in ___

younger population open repair has higher blood loss seizures as a result of vascular steal syndrome

Complications of non-cutting

requires more force

According to the American society of anesthesiologists, what is the incidence of anesthetic mortality in the asa1 patient population?

.04 per 10000 anesthetics

What is the angle of a Crawford needle?

0 degrees

Morphine Intrathecal dose Epidural dose Epidural Infusion dose

0.25 - 0.30 mg 2 - 5 mg 0.1 - 1 mg/hr

Landmarks for the Infraclavicular Block

1 = coracoid process 2 = clavicle 3 = humerus 4 = scapula

Where is the *deep peroneal n.* blocked?

Between the tendons of the anterior tibial and extensor digitorum longus muscles

What is the proposed mechanism for HoTN + bradycardia during shoulder arthroscopy w/ an interscalene block?

Bezold-Jarisch reflex

Paget's disease

Excess osteoblastic and osteoclastic activity tinnitus, bone pain, enlargement of bone, thick bones Cause: Excessive parathyroid hormone or calcitonin deficiency Can cause peripheral nerve entrapment NO vascular involvement

Metabolism/elimination of gabapentin

Excreted unchanged via the kidneys

Gabapentinoids (Gabapentin, Pregablin) MOA, metabolism

Inhibition of the alpha 2 delta subunit of voltage gated calcium channels in the CNS - ↓ excitatory nt release -not a GABA agonist and does not get metabolized to GABA Excreted unchanged in the kidneys, do not cause hepatic induction Also useful for neuropathic pain

What may occur with simultaneous administration of valproic acid and phenytoin?

Inhibits phenytoin metabolism - displaces from plasma proteins

Where do you inject LA for a *median n.* block at the wrist?

Inject 5mL btwn the flexor carpi radialis tendon and the flexor palmaris longus tendon

How do you block the *radial n*. in the forearm? Volume in ml? Where does it derive from?

Inject btwn *biceps tendon* and *brachioradialis* Volume = 3-5mL -posterior cord brachial plexus

How is c6 neuropathy developed?

Injecting LA into the neuron - compresses the nerve root against tubercle pts may develop crampy sensation

Most common sign of Subarachnoid Hemorrhage (SAH)

Intense headache "worst one in my life" Consciousness lost in 50% Other s/sx: focal deficits, N/V, photophobia, fever

Axillary indications and landmarks

Indications: forearm & hand Landmarks: axillary artery pulse, coracobrachialis muscle 9 (musculocutaneous nerve passes thru it), humerus

Contraindication for bier block

Infection of extremity Poor circulation Seizure disorder Heart Block Allergy

Ehlers-Danlos syndrome definition

Inherited disorder of procollagen and collagen (spontaneous bleeding into joints and AAA)

MOA of neuraxial opioids

Inhibit afferent pain transmission in substantia gelatinosa (lamina II) of the dorsal horn Epidural opioids also diffuse into systemic circulation, where blood delivers them to opioid receptors throughout the body

Anti-rheumatic drug MOA

Inhibit tumor necrosis factor (TNF), interleukin-1 & 6 Inhibits T cells & B lymphocytes (Immunosuppresant) Methotrexate, cyclosporine, etanercept methotrexate causes liver dysfxn & suppresses bone marrow Cyclosporine prolongs duration of Succ

MOA of gabapentin

Inhibition of alpha 2-delta subunit of ca+ channels in the CNS --> decreased excitatory NT release

In addition to a Brachial Plexus block, which nerve must also be anesthetized for a patient to tolerate an UE Tourniquet?

Intercostobrachial n. - arises from T2

Which arteries supply the anterior circulation of the brain? Order?

Internal carotid arteries Aorta-->Carotid a--> Internal carotid a.--> Circle of Willis--> Cerebral hemispheres

Which UE block approach often blocks the stellate ganglion?

Interscalene block

Which BP block is most likely to cause *phrenic nerve paralysis*?

Interscalene block (ipsilateral hemiparesis of diaphragm)

What artery is most likely to be inadvertently injected with each brachial plexus block

Interscalene: Vertebral Supraclavicular: Subclavian Infraclavicular: Subclavian or axillary Axillary: Axillary

Lipid rescue protocol:

Intralipid 20% 1.5ml/kg over 1min then infusion .25ml/kg/min

What is another name for a *psoas compartment* block?

Lumbar plexus block

Which choice is the MOST potent amnestic? Choices:Diazepam, Midazolam, Flurazepam, Lorazepam

Lorazepam (up to 6hrs of amnesia)

Selegiline

MAO-B inhibitor Restores dopamine concentration by reducing dopamine metabolism in the CNS *Does not increase the risk of tyramine-induced hypertensive crisis

Selegiline

MAO-B inhibitor = inhibits the metabolism of dopamine in the basal ganglia

_____ pushes outward against aneurysmal sac, ______ is the counter pressure that pushes against. ______ creates tamponade effect.

MAP ICP ICP

Transmural pressure equation

MAP - ICP

Occular perfusion pressure

MAP - IOP

absolute contraindications to ECT include

MI within 4-6weeks stoke within 3 months intracranial surgery within 3months brain tumor unstable cervical spine pheochromocytoma

C sympathetic peripheral nerve fibers

No myelination Function: Postganglionic ANS fibers Diameter: 0.3 - 1.3 µm Velocity: Slowest Block onset: second

C Nerve Fiber (sympathetic) -Myelination -Function -Diameter -Conduction velocity -Block onset

No myelination Function: Postganglionic ANS 0.3 - 1.3 + 2nd

Which nerve is most commonly missed in a 3-in-1 block?

Obturator n.

The anterolateral system (spinothalmic tract) transmits what type of sensations?

Pain, temp, crude touch, tickle, itch, sexual sensation

Treatment for Alzheimer's

Palliative- aims to restore concentration of Ach Cholinesterase inhibitors such as tacrine, donepezil, rivastigmine, and galantamine

Where do third order neurons of the dorsal column travel?

Pass through the internal capsule and advance toward the somatosensory cortex in the post central gyrus in the parietal lobe

NO EFFECT on Risk of PDPH

Patient Factors - early ambulation Provider Factors - continuous spinal cath (if placed after spinal block)

Methods to protect against dysrhythmias with MH

Procainamide 15mg/kg IV Lidocaine 2mg/kg IV Do NOT give a CCB - can precipitate life-threatening hyperkalemia

What is auto regulation influenced by?

Products of local metabolism, myogenic mechanisms(vascular smooth muscle contraction), and autonomic innervation

Pyridostigmine ____________ the duration of Succ

Prolongs It impairs the efficacy of pseudocholinesterases

Median nerve movement

Pronation of forearm Flexion of wrist Opposition of the middle, forefinger and thumb

Procedure risk factors for ION

Prone, Wilson frame, long duration of anesthesia, large blood loss, low ratio of colloid:crystalloid, hypotension

Intraoperative BP during aneurysm surgery

SBP: 120-150mmHg High normal BP is required to perfuse collateral vessels while clamp is on If no clamp is use, controlled hypotension may be requested to prevent aneurysm rupture

Anesthetic consideration for sickle cell anemia

SC disease (homozygous) not SC trait (heterozygous) increases risk of mortality. pain, hypothermia, acidosis, dehydration increase sickling

Where does the spinal cord end?

SC ends in a taper as the conus medullaris

*Interscalene block* Ultrasound Image

SCM= Sternocleidomastoid ASM= anterior scalene MSM= Middle scalene

Cerebral Perfusion Pressure SBP range and MAP range -Formula

SBP 50-150 mmHg OR MAP 60-160 mmHg CPP = MAP-ICP (or CVP, whichever is higher)

What will you see on the screen with short axis imaging?

Short axis will see dots Ex: if doing an US on a radial artery, will show up as a DOT

What procedures are not well suited for a *supraclavicular block*?

Shoulder surgeries - does not anesthetize the suprascapular n., which arises from the proximal upper trunk

What does a Cobb angle of 100 indicate

Significant gas exchange impairment and higher risk of postop pulmonary complications

Caudal Block technique

Sims position prone: Roll under iliac crest, Legs In frog position 22 To 25 gauge needle Or 20 gauge IV catheter Bevel up Through sacral hiatus at 45° angle Advancing to feel a pop, Drop angle

When is the BBB dysfunctional?

Sites of tumor, injury, infection, or ischemia

What occurs when CPP is less than 50?

Vessels are maximally dilated CBF becomes pressure dependent Risk of cerebral hypoperfusion

Cranial Nerve VIII -Nerve name -Function -Bedside test

Vestibulocochlear Sensory Hearing and balance

What is the function of Pacinian corpuscles?

Vibration

3 factors that disrupt autoregulation

Volatile anesthetics Head trauma Intracranial tumor

Primary determinant of spread in epidural anesthesia

Volume

What determines the height of a sacral block?

Volume

Jacksonian march

When a partial seizure progresses to a generalized seizure

When is the psoas block useful? (2)

When neuraxial anesthesia is contraindicated Want anesthesia to one lower extremity only

Diagnosis for AO subluxation

When the distance between the anterior arch of the atlas and the otonoid process is > 3mm

Glasgow Coma Scale (GCS)

a scoring system used to describe the level of consciousness in a person following a traumatic brain injury

Match each blood type with the corresponding antibody you would find in its serum: a) A b) AB c) B d) O

a) A - antiB b) AB - none c) B - antiA d) O - anti A and B

Which is expected to decrease in the elderly?

PaO2

DOPA decarboxylase facilitates conversion of:

DOPA to dopamine

What blocks can you not use epi in?

Digit or end-organ (ears, toes, penis, fingers)

Renal complications of RA

Renal insufficiency d/t vasculitis and NSAIDs

Where do the internal carotids enter the skull? (Anterior circulation)

Through the foramen lacerum

Where do the vertebrals enter the skull? (Posterior circulation)

Through the foramen magnum

Which gland plays a key role in myasthenia gravis? What brings relief of symptoms?

Thymus gland; thymectomy

Differential diagnosis of MH v. other possibilities *just to be aware

Thyroid storm Malignant neuroleptic syndrome Sepsis Pheochromocytoma Serotonergic syndrome Heat stroke metastatic carcinoid Cocaine intoxication

MH differential diagnosis

Thyroid storm Neuroleptic malignant syndrome Pheochromocytoma Sepsis Serotonergic syndrome Heat stroke Metastatic Carcinoid Cocaine intoxication

Match ADP receptor inhibitor with the number of days it should be discontinued prior to elective surgery Ticlopidine, ticagrelor, clopidogrel, prasugrel

Ticagrelor- 1-2days Prasugrel- 2-3days Clopidogrel- 7days Ticlopidine- 14days all are metabolized by the liver

What lung volumes increase in the pregnant patient? (2)

Tidal volume (30%) Inspiratory reserve volume

T/F, an axillary block may require more multiple injections?

True

What do the trunks divide into?

Trunks divide into Anterior and Posterior Divisions

Where do the trunks turn into divisions?

Trunks split into divisions *underneath clavicle* and *over 1st rib*

List the branches of CN VII and function

Two zebras bit my cat Temporal Zygomatic Buccal Mandibular Cervical Both motor and sensory Facial movement, eyelid closing, taste for anterior 2/3 of tongue

What is the function of Meissner's corpuscles?

Two-point discriminative touch and vibration

Oligodendrocytes

Type of glial cell in the CNS that wrap axons in a myelin sheath. Schwan cells form the myelin sheath in the PNS

CREST syndrome

Type of scleroderma Calcinosis, Raynaud's, esophageal dysmotility, Sclerodactyly, Telangiectasia

GI complications of RA

Ulceration d/t NSAIDs and steroids

what will you see in a block/lesion to the ulnar nerve ?

Ulnar (C 8, T1) *"Clawing"* of fingers 3 & 4- M.P. joints hyper extended; Thumb - abducted and extended - adductor pollices. Sensory Deficit- Ulnar and dorsal aspect of palm and of ulnar 1 1/2 digits

This nerve is derived from the medial cord. Motor innervation is mainly to intrinsic muscles of the hand. Sensory innervation is from the medial ( ulnar) 1 & 1/2 digits ( the 5th. and 1/2 of the 4th. digits). Claw hand.

Ulnar nerve [Claw hand, 'pope benediction']

What does the interscalene not block?

Ulnar nerve. Less suitable for procedures on the hand b/c C8-T1 harder to block from this approach *Ulnar nerve is often missed when doing an interscalene block*

T10 sensory innervation

Umbilicus

Contraindications to peripheral nerve blocks:

Uncooperative patient Patient refusal Sedated Patient Bleeding disorders/abnormalities Infection Local anesthetic allergy or toxicity Peripheral neuropathies

Target pressure following ischemic CVA

Under 185/110 Fluid replacement supports, BP,CO, CPP- also improves CBF by decreasing viscosity

Wernicke's area

Understanding speech

The cause of Familial periodic paralysis is:

Unknown

Which laminae are motor?

VII - IX

Which nerve is responsible for 75% of all parasympathetic activity?

Vagus

Cranial Nerve X -Nerve name -Function -Bedside test

Vagus Both Swallowing

What cardiac pathologists present a risk of HD collapse with neuraxial anesthesia?

Valve lesions w/ fixed SV: - severe aortic stenosis - severe mitral stenosis - hypertrophic cardiomyopathy

What is Batson's plexus? What is its significance?

Valveless epidural veins that drain venous blood from the spinal cord passing through anterior and lateral regions of epidural space Obesity + pregnancy increase intra-abd pressure, causing engorgement of the plexus - Increased risk of needle injury/cannulation during neuraxial techniques

Most significant source of morbidity and mortality in a patient with SAH

Vasospasm

Compared to the adult, which is higher in the newborn (2)

Vd for water soluble drugs Extracellular fluid volume

basal ganglia

fine control of movement

Acceptable response to twitch monitor (infraclavicular)

finger twitch

injury below the level of decussation in the medulla

flaccid paralysis on the ipsilateral side of the body

Guillain-Barre clinical presentation & Cause

flu-like symptoms precede paralysis Cause: Camplyobacter jejuni bacteria, Epstein Barr virus, Cytomegalovirus. Other causes: vaccinations, surgery, lymphomatous disease

TIA

focal neurologic deficit that spontaneously resolves w/in 24h

Cranial border of the epidural space

foramen magnum

How does Epi affect LA?

induces local vasoconstriction so slows blood absorption therefore prolongs duration

Bier blocks are best used in surgeries that have minimal:

post operative pain bc the lidocaine gets flushed out with tourniquet release

Lumbar spinous process project in a _________ direction

posterior Makes access easier

Cords

posterior: C5-T1 medial: C5-C7 lateral: C8 -T1

What can lessen the risk of bezold jarisch reflex?

preop Beta blockade

Cerebral blood flow graph: which represents ICP

A-PaO2 B- PaCO2 C- CPP D- ICP

What causes restrictive lung disease in Duchenne?

Kyphoscoliosis, which decreases pulmonary reserve

Which nerve roots give rise to the *iliohypogastric nerve*?

L 1

Which nerve roots give rise to the *ilioinguinal nerve*?

L1

Which nerve roots give rise to the *genitofemoral nerve*?

L1 + L2

Focal cortical seizure

Localized to one cortical region can be motor or sensory Usually no loss of consciousness

Broca's area location and function

Located in temporal lobe Motor control of speech

Wernicke's area location and function

Located in temporal lobe Understanding speech

*Hydrophilic* Opioids: Duration

Longer (6 - 24 hours)

*Lipophilic* Opioids: Pruritus

Lower incidence

Benefits of non-cutting tip

Lowers risk of PDPH More tactile feel Needle less likely to deflect Less likely to injure the cauda equina

The superior iliac spine coincides with:

S2 Location of the dural sac in adults Neonates dural sac: S3

What is the MAC of isoflurane in the full term parturient (pregnant)?

0.6% in FT pregnant pt MAC is reduced 40%

Crawford epidural needle

spinal cord circulation

2 posterior spinal arteries 1 anterior spinal artery 6-8 radicular arteries

Which LA can REDUCE the EFFICACY of EPIDURAL opioids?

2-Chloroprocaine

Max does of Bupivicaine for peripheral nerve block?

2.5 mg/kg or 250 mg

For peds specifically, any concentration of bupi, levobupi, ropivacaine can be used as long as total dose doesnt exceed

2.5-3 mg/kg

Dantrolene dose

2.5mg/kg IV, repeat q 5-10min if pt requires more than 20mg/kg reconsider diagnosis

What volume of LA is appropriate for a *psoas compartment* block?

20 - 30 mL

MRI scanner should be located in zone:

4 - very limited access with very strict supervision

Cobb angle wwhen respiratory s/s appear

70

Cobb angle associated with pulmonary symptoms

70 degrees

Microglia

Act as phagocytes, eating damaged cells and bacteria, act as the brains immune system

TIA

"Mini stroke" - focal neurologic deficit that spontaneously resolves within 24 hours

Draw the femoral triangle

"SAIL" of a ship S = Sartorius m. A = Adductor longus m. IL = Inguinal ligament

Ganglion

A collection of cell bodies that reside outside of the CNS

What connects the hemispheres of the brain?

Corpus callosum -Located deep in the longitudinal fissure

Brachial plexus [image]

Be able to draw this!

Roots

C5-T1

Earliest symptoms of myasthenia gravis

Diplopia(double vision), ptosis (eye droop)

Musculocutaneous nerve mvmt.

Flexion at elbow

Which nerve is not anesthetized with any approach of the brachial plexus block?

Intercostobrachial nerve

complications of the Infraclavicular Block?

Pneumothorax, Chylothorax , Hemothorax

*Lipophilic* Opioids: Duration

Shorter (2 - 4 hours)

*Lipophilic* Opioids: Onset

Fast (5 - 10 min) *fentanyl, sufentanil

Clinical presentation of Guillain-Barre

Flu-like illness precedes paralysis by 1-3 weeks

What phenomenon occurs when the stellate ganglion is blocked?

Horner's Syndrome

Jet Ventilation

can be used above the glottis can cause a pneumothorax

ganglion

collection of nerve cell bodies that reside outside of the CNS

mitral insufficiency is associated with

eccentric hypertrophy and volume overload

Scleroderma

excessive fibrosis in skin and organs

What do you want to see if interscalene block in right place?

Looking for hand, arm and bicep contraction

What structures reside in the adrenal medulla? (2)

Loop of Henle Collecting ducts

Sacral Cornua -Definition -Result from

-Boney nodules that flank the sacral hiatus -Result from the incomplete development of the facets

VAE signs

↑EtCO2 ↑EtCO2 & PaCO2 gradient

Describe the anatomical position of the *femoral n.*

- biggest of the 3 nerves - forms near middle and lower 3rd of psoas muscle - courses distally in groove created by psoas major and iliac muscle - continues under inguinal ligament - lies anterior to iliopsoas muscle, lateral to to femoral a.

Describe the 3 signs/symptoms of the *Bezold-Jarisch* reflex

- bradycardia - HoTN - syncope

An *interscalene block* is NOT good for procedures below the __________, as it frequently spares roots ____________.

- elbow - C8-T1 (lower trunk)

Sphenopalatine ganglion block

1 to 2% lidocaine or 0.5% Bupivacaine Sniffing position Leave cotton tipped applicator in nose 5 to 10 minutes

Multiple sclerosis 4 anesthetic implications to know

1) spinals can exacerbate symptoms 2)hyperthermia can exacerbate symptoms 3) succinylcholine can cause hyperkalemia 4) seroids are useful for MS

How long may neurogenic shock last?

1-3 weeks (neurogenic shock for a few weeks, then dysreflexia may happen when there is stimulation)

4 cardinal signs of Parkinson's

1. Resting "pill rolling" tremor 2. Rigidity (increased muscle tone) 3. Bradykinesia (slowed movement) 4. Postural instability - loss of balance w/ altered gait 2 of the 4 signs is diagnostic

What are the 2 complications of a *psoas compartment* block?

1. Retroperitoneal hematoma 2. Renal capsular injection

Major Anesthetic considerations for Gullian Barre (3)

1. Skeletal muscle denervation 2.Impaired ventilation 3. Autonomic dysfunction

What are the 3 ABSOLUTE contraindications to caudal anesthesia?

1. Spina bifida 2. Meningomyelocele of sacrum 3. Meningitis

Rank the opioids from most lipophilic to most hydrophilic

1. Sufenta 2. Fentanyl 3. Meperidine 4. Hydromorphone 5. Morphine

5 ligaments of the spinal column in order from superficial to deep

1. Supraspinous ligament 2. Interspinous ligament 3. ligamentum flavum 4. Posterior longitudinal ligament 5. Anterior longitudinal ligament

Consequences of increased intracellular calcium

1. Sustained muscle contraction 2. Accelerated metabolic rate and rapid depletion of ATP 3. Increased O2 consumption 4. Increased heat & CO2 production 5. Mixed respiratory and metabolic acidosis 6. Sarcolemma breaks down 7. Potassium and myoglobin leak into systemic circulation 8. Rigidity and sustained contraction

Postoperative concerns for myasthenia gravis (3)

1. Very sensitive to effects of residual NMBlockade 2. Bulbar muscle weakness (mouth and throat)- difficulty handling oral secretions- increased risk for aspiration 3. May need postop mechanical ventilation- need to let patients know its a risk

Urinary retention caused by neuraxial opioids: More common young males/females? More common in IV/IM/Neuraxial? Results from inhibition of: What reverses it?

1. Young males 2.Neuraxial 3. Inhibition of sacral parasympathetic tone- causes bladder detrusor muscle relaxation and urinary sphincter contraction 4.Reverse with naloxone

What are the 2 most common side effects of an epidural blood patch?

1. backache 2. radicular pain

Order of CSF flow

1. choroid plexus 2. lateral ventricles 3. 3rd ventricle 4. Aqueduct of Sylvias 5. 4th ventricle 6. Foramen of Luschka 7. Foramen of Megendie 8. subarachnoid space + central canal -> superior sagittal sinus

4 sites of brain herniation

1. cingulate gyrus under the falx 2. tentorium cerebelli (transtentorial) 3. cerebellar tonsils through the foramen magnum 4. through the site of surgery or head trauma (ie an unnatural opening in the skull)

Interscalene landmarks [image]

1. clavicle 2. posterior border of the sternocleidomastoid muscle 3. EJ 4. Cricoid Cartilage C6 =adams apple.

Relative contraindications to neuraxial anesthesia

1. coagulopathy: risk of hematoma, PLT < 100,000, PTT, aPTT, or bleeding time twice normal level 2. ↑ICP = change is CSF pressure 3. Sepsis 4. Infection at the puncture site 5. Hypovolemia = worsening of HoTN d/t sympathectomy 6. Scoliosis, arthritis, spinal fusion, osteoporosis (technical difficulty) 7. Difficult airway = complicates quickly converting to GA if block fails 8. Peripheral neuropathy = slow recovery, more susceptible to injury 9. Multiple sclerosis = epidural is safe but intrathecal may cause exacerbation (an NCE thing - not true in practice)

Treatment of neurogenic shock

1. fluid resuscitation 2. atropine 3. vasopressor (norepi) No Succ (esp. 24 after time of injury)

What increases the risk of respiratory depression w/ neuraxial opioids

1. higher doses 2. co-administered sedatives 3. low lipid solubility 4. advances age 5. opioid naivety 6. increased intrathoracic pressure

Order of recovery in differential blockade

1. motor 2. touch 3. pinprick (fast pain) 4. Temperature 5. pre-ganglionic sympathetic Anesthetized in the opposite order

Morbidity related to SAH is usually the result of...

1. obstructive hydrocephalus 2. rebleeding 3.vasospasm

The sciatic n. MOTOR innervation: Provides motor and sensory info to:

1. posterior thigh 2. lower leg + foot via branches (tibial + common peroneal)

myasthenia gravis postoperative concerns

1. sensitive to residual effect of nmb's 2. bulbar muscle weakness -> increased risk of pulmonary aspiration 3. possible postop mechanical ventilation

Methods to reduce ICP

1. ↓Cerebral blood volume 2. ↓CSF 3. ↓cerebral edema 4. ↓cerebral mass

How far should you advance the epidural catheter? -too shallow -too deep

3-5cm inside the epidural space too shallow: increased risk inadequate anesthesia Too deep- may enter epidural vein or exit thru intervertebral foramen

What is the angle of a Tuohy needle?

30 degrees

How much LA is used with a supraclavicular block?

30 to 40cc of 1.5% lidocaine, .375-.5 of Bupivacaine or Ropivacaine

When properly placed, the ProSeal LMA allows a positive ventilation pressure of?

30cm H2O

The effect of hyperventilation on CBF lasts for ___ hours. -Why does it stop working?

6-20 hours -The pH of CSF equilibrates with PaCO2 *CO2 reactivity is usually preserved even in traumatized brains

Cobb angle with decreased pulmonary reserve

60

Cobb angle associated with decreased pulmonary reserve

60 degrees

Glucose content in CSF vs. plasma

60 in CSF vs. 90 in plasma

Oxygen utilization in the brain -Electrical activity -Cellular integrity

60% for electrical activity 40% for cellular integrity -Even if the brain is electrically silenced it still consumes O2 to support cellular integrity

Which disorder is common in patients with Eaton-Lambert syndrome?

60% have small-cell (oat-cell) carcinoma of the lung- consider this for patients with lung cancer that are undergoing mediastinoscopy. bronchoscopy, thoracoscopy

Maximum inflation pressure of the LMA classic?

60cm H2O

A patient received a citrated non-particulate antacid, but the case has been delayed. How long after the initial dose should a second dose be considered?

60minutes

pH of CSF

7.33 (PaCO2 47 in CSF)

What is a common mode of failure with interscalene blocks?

A common mode of failure in interscalene blocks of the brachial plexus under ultrasound guidance is injection into the body of the anterior or middle scalene muscle.

What causes a PDPH

A decrease in the amount of CSF in the subarachnoid space causing the medulla & brainstem to drop into the foramen magnum.

Normal Babinski Response

A firm stimulus to the underside of the foot produces a downward motion of all toes

Babinski sign with damage to the upper motor neurons in the corticospinal tract

A firm stimulus to the underside of the foot produces an upward extension of the big toe with fanning of the other toes

A high venous pressure increases/decreases cerebral venous drainage and increases/decreases cerebral volume. -Significance?

A high venous pressure decreases cerebral venous drainage and increases cerebral volume. -Creates backpressure to brain that reduces arterial/venous pressure gradient (MAP-CVP)

How does a *hyperbaric* solution distribute in the *sitting* patient?

A hyperbaric sol'n will settle to the lowest point of the spinal canal Keep pt sitting w/ hyperbaric = *sacral nerve roots* anesthetized (SADDLE BLOCK)

Chronic treatment of hydrocephalus

A shunt drains CSF to the peritoneal cavity (ventriculperitoneal shunt) or the right atrium (ventriculoatrial shunt)

What is a chylothorax?

A type of pleural effusion. It results from lymph formed in the digestive system called (chyle) accumulating in the pleural cavity due to either disruption or obstruction of the thoracic duct.

Which drugs may reduce CSF production?

Acetazolamine and furosemide

The *femoral n.* provides SENSORY innervation to ______________.

Anterior thigh

(2) true statements about EMLA cream?

Adequate anesthesia is obtained in 60minutes. It can cause methemoglobinemia 2.5% lidocaine 2.5% prilocaine

How do you differentiate between a cholinergic crisis and a myasthenic crisis? What is the test called?

Administer 1-2mg IV edrophonium - if weakness gets worse, it's cholinergic crisis. If there is improvement in muscle strength, myasthenic AKA the Tensilon test

Endocrine complications from RA

Adrenal insufficiency and infections d/t steroids

Endocrine complications of RA

Adrenal insufficiency and infections d/t steroids

Where does the dural sac end?

Adult: S2 - correlates with the superior iliac spines infant: S3 subarachnoid space terminates at the dural sac

The grey matter in the spinal cord is the processing center for which signals entering from where?

Afferent signals coming from the periphery

Anesthetic considerations involving use of volatile anesthetics in the obese population

Agents with lowest Blood: gas coefficients provide the fastest emergence. Less accumulation in the fat. MAC is unchanged by obesity

Complications of the prone position

Airway edema - leak test ETT mainstem or kink Cerebral hypoperfusion - neck rotation -> venous compression Ischemic optic neuropathy Corneal abrasion brachial plexus injury Ulnar n injury DVT (hip flexion -> femoral vein occlusion) Lateral femoral cutaneous n. injury (iliac crest pressure) peroneal n. injury (Lateral fibula pressure) ↑abdominal pressure

Scleroderma anesthetic considerations

Airway: limited mouth opening Respiratory: Pulmonary fibrosis & pulmonary HTN Heart: Dysrhythmias and CHF Blood vessels: decreased compliance -> HTN Kidneys: renal failure & renal artery stenosis -> HTN Peripheral & cranial nerves: nerve entrapment -> neuropathy eyes: dryness -> corneal abrasion

Sphenopalantine Ganglion block: Is the alternative to _____ Steps to preform 1-6:

Alternative to Blood patch 1. soak cotton tip applicator in LA (1-2% lido or 0.5% bupi) 2. place pt in sniffing position 3. insert applicator into each nare towards middle turbinate 4. Insert until posterior wall of nasopharynx is reached- this is where the sphenopalantine ganglion are 5. leave applicator there for 5-10min 6. pt should notice symptom improvement

Clonidine 1mcg/kg provides what?

Analgesia that is equal to opioid analgesia

Techniques For Peripheral Nerve Blocks

Anatomic Localization Field Block Elicitation of Paresthesia (Blunt) Perivascular Sheath (Sheath pop) Transarterial placement Nerve Stimulator ( 1mA highly specific .5mA nearly 100% successful) Ultrasound

Median Nerve wrist block

Anatomic landmarks: flexor carpi radial tendon & flexor palmaris longus tendon Inject 5mL between the flexor carpi radial tendon and the flexor palmaris longus tendon

Radial Nerve wrist block

Anatomic landmarks: radial styloid Subq injection = 10mL proximal to the radial styloid (field block)

Ulnar Nerve wrist block

Anatomic landmarks: ulnar styloid, ulnar pulse, flexor carpi ulnaris tendon Inject 3-5mL medial to and below the flexor carpi ulnaris tendon

Most common hematologic complication of RA?

Anemia Platelet dysfunction is d/t NSAID use

Hematologic complications of RA

Anemia Platelet dysfunction secondary to NSAIDs

What might you see once interscalene block achieved?

Anesthesia is then evaluated in 5 min. Weakness of biceps or sensory anesthesia of forearm. Horners Syndrome SOB

popliteal nerve block anesthetizes all of the these 3 nerves ___ but not ____

Anesthetizes the sciatic nerve and its branches(common peroneal and tibial) Saphenous nerve is a branch of the femoral nerve. It is not blocked by a popliteal nerve block

Most common cause of subarachnoid bleeding

Aneurysm rupture

Order the 5 ligaments of the spinal column from posterior to anterior

Answer next page

What do MEPs test?

Anterior cord Anterior spinal artery Motor function - NO NMB's

Effect of maternal MG on the neonate

Anti-AchR IgG antibodies cross the placenta and cause weakness in 15-20% of neonates that may persist for 2-4 weeks (consistent wit the 1/2 life of Anti-AchR IgG antibodies in the neo's circulation) *those neonates may require airway management when born

Treatment of MG

Anticholinesterases- pyridostigmine Immunosuppression-corticosteroids,cyclosporin, azathioprine, mycophenolate Thymectomy- (approach via median sternotomy or transcervical) Plasmapheresis- temporary relief during MG crisis or prior to thymectomy

First line treatment of MG

Anticholinesterases: Oral pyridostigmine

Which drugs should be avoided in a patient with Parkinson's?

Antidopaminergics (metoclopramide, butyrophenones like haldol/droperidol, phenothiazines) Alfentanil Possibly ketamine (controversial) *exacerbate extrapyramidal sx

Hematologic complications of SLE

Antiphospholipid antibodies Hypercoagulability Anemia Thrombocytopenia Leukopenia

Use of bupivicaine, levobupivicaine, ropivicaine in pediatrics

Any concentration is ok as long as dose does not exceed 2.5mg/kg

Unacceptable response to twitch monitor (axillary)

Anything else

Anterior spinal artery circulation

Aorta - subclavian - vertebral - anterior spinal Aorta - segmental - anterior radicular - anterior spinal

Anterior cerebral circulation

Aorta -> Carotid artery -> Internal carotid artery -> Circle of Willis -> Cerebral hemispheres enter the skul through the foramen lacerum

Guillain-Barre S/S

Ascending muscle weakness up to face (distal to proximal) Intercostal muscle weakness (may need mechanical ventilation) Facial and pharyngeal weakness -> aspiration risk Sensory deficits: paresthesias, numbness, &/or pain ANS dysfxn: tachy or brady-cardia, HTN or HoTN, diaphoresis or anhidrosis, orthostatic HoTN

Risks to consider w/ Myotonic dystrophy

Aspiration Respiratory muscle weakness cardiomyopathy & dysrhythmias Sensitive to anesthetic agents (No increased risk for MH)

If tPA can't be administered for an ischemic stroke, what may be given as an alternative?

Aspirin

Which type of glial cell is most abundant?

Astrocytes

Where do the two venous pathways of the brain converge?

At the confluence of sinuses

Most common site of transtentorial herniation

At the temporal uncus -As ICP rises, the temporal uncus is forced from the supratentorial space into the infratentorial space which increases pressure on the midbrain

Metabolites of which drugs may produce seizure activity?

Atracurium (laudanosine) and meperidine (normeperidine) *cisatracurim also produces laundanosine, but much smaller quantities

NMB that can be implicated in seizures

Atracurium d/t laudanosine production - mostly caused by long term infusions Laudanosine is also a metabolite of Cis, but it is produced in much smaller quantities.

Anesthetic considerations for hyperkalemic periodic paralysis What not to administer? What is okay to administer?

Avoid succinylcholine and potassium-containing solutions (LR) Okay: Glucose containing fluids, K+waste diuretics, B2 agonists, NDNMB, Acetazolamide

For DBS the patient needs to be:

Awake or lightly sedated can lightly sedate with opioids or precedex

what will you see in a block/lesion to the axillary nerve ?

Axillary (C 5,6 ) Difficult abducting arm to horizontal - Deltoid. Sensory deficit- Lateral side of arm below point of shoulder *"inability to abduct arm"* [can be injured from arm hanging off OR table]

Axillary nerve

Axillary nerve is derived from the posterior cord. Motor innervation is deltoid and theres minor muscles that act on the shoulder joint. Sensory innervation is from the skin just below the point of the shoulder. [Shoulder drop]

Which vertebrae does the *coccygeal plexus* arise from?

S4 - Co

Neuraxial recommendations w/ warfarin

B/f block hold 5d catheter can be removed when INR < 1.5

Factors that don't affect spread of spinal anesthesia

Barbotage Increased intra-abdominal pressure Speed of injection Orientation of bevel Addition of vasoconstrictor Weight Gender

steal phenomenon

Blood vessels that supply ischemic or atherosclerotic regions are maximally dilated. Therefore anything that causes cerebral vasodilation (↑PaCO2/vasodilators) can decrease the blood supply to these ischemic tissues as some of it is diverted to newly dilated vessels

Detail the dosing and drugs commonly used for a continuous *femoral n.* block

Bolus + 8-10mL/hr 0.2% Ropivicaine or 0.25% Bupivicaine

Axillary block level

Branches

How does the brain compensate for increased volume of CSF or blood?

CSF is shunted to the spinal canal -horizontal portion of ICP curve -As intracranial volume rises, CSF cannot compensate and CPP suffers

The posterior branch of the *femoral n.* gives rise to the ________________ nerve.

SAPHENOUS (nerve)

CSF volume and specific gravity

CSF volume: ~150mL CSF specific gravity: 1.002 - 1.009 produced by ependymal cells at rate of 30mL/h

Contents of the subarachnoid space

CSF, nerve roots, rootlets, spinal cord (spinal cord is covered by the pia mater)

Channel dysfxn associated w/ Hypokalemic periodic paralysis

Ca+ channelopathy

Where is the superior trunk located?

C5-C6

Most common site of spinal cord injury

C7

When the action potential depolarizes the nerve terminal what is limited?

Ca+ entry into the presynaptic terminal which reduces the amount of Ach mobilized and released in synaptic cleft

Method of treating hyperkalemia with MH

CaCl 5-10mg/kg Insulin 0.15 U/kg and D50 1mL/kg Hyperventilation

Arterial Oxygen Content

CaO2= (SaO2 x Hb x 1.34) + (PaO2 x 0.003)

What medication class should never be given with MH

Calcium channel blocker - can precipitate Hyperkalemic cardiac arrest when given with Dantrolene

Dexmedetomidine (2 reactions)

Can cause HTN(central A2 stimulation causes vasodilation, sedation, and analgesia. Peripheral stimulation initiates vasoconstriction) reduces adenylate cyclase(stimulation of G protein inhibits adenylate cyclase and reduces cAMP)

Inhaled anesthetic effect on seizures

Can cause seizures but usually EEG activity is suppressed in a dose dependent fashion

Adductor Canal block

Can provide analgesia for knee surgery w/o affecting quadriceps function- pts can ambulate sooner after surgery

What areas of the brain are not protected by the BBB

Chemo trigger zone, posterior pituitary gland, pineal gland, choroid plexus, part of hypothalmus

Where is the BBB not present? (CCPPP)

Chemoreceptor trigger zone (CTZ) Choroid plexus Posterior pituitary gland Pineal gland Parts of the hypothalamus

An overdose of anticholinesterases in myesthenia gravis can cause:

Cholinergic crisis and muscle weakness (cholinergic crisis can be difficult to differentiate from myasthenic crisis)

Ketorolac should be avoided in all except: (samters triad, PUD, renal insufficiency, chroncic bronchitis)

Chronic bronchitis

The anterior and posterior circulations converge at the:

Circle of Willis

Differential block

Clinical phenomenon that nerve fibers with different functions have different sensitivities to local anesthetic blockade

What can be reversed with platelet transfusion?

Clopidogrel or aspirin Also some evidence of reversal with recombinant factor VIIa

Neuraxial recommendations w/ Thienopyrodine derivatives

Clopidogrel: b/f block placement hold 7 days Ticlodipine: b/f block placement hold 14 days

What is the one contraindication to a *psoas compartment* block?

Coagulopathy

Which angle describes the magnitude of the spinal curvature?

Cobb

Cerebral cortex functions

Cognition, sensation, movement -Structure of the cerebral hemisphere

Sacral hiatus

Coincides w/ S5 -covered by the sacrococcygeal ligament -provides entry point to the epidural space

Methods to cool the patient

Cold IVF Cold fluid lavage of stomach and bladder Ice packs

Which two nerves converge in the *sacral plexus* to make the *sural nerve*?

Common peroneal n. + Tibial n.

Which two nerves converge in the *sacral plexus* to make the *sural nerve*?

Common peroneal n. + Tibial n.

*Sacral Plexus* In the Ankle

Common peroneal n. gives rise to: - Superficial peroneal n. - Sural n. Deep peroneal n. Tibial n. gives rise to: - Posterior tibial n - Sural n.

*Sacral Plexus* In the Ankle

Common peroneal n. gives rise to: - Superficial peroneal n. -Deep peroneal n. - Sural n. Tibial n. gives rise to: - Posterior tibial n. - Sural n.

Plica mediana dorsalis

Connective tissue between ligamentum flavum and dura mater (in epidural space) - theoretical - considered to be a cause for difficult epidural cannulation and unilateral blocks

Marfan syndrome definition

Connective tissue disorder with autosomal dominant inheritance (aortic insufficiency and AAA) *Minimize wall stress with BB

Osteogenesis imperfecta definition

Connective tissue disorder with autosomal dominant inheritance, resulting in weak bones

White matter contains what? What is it divided into?

Contains the axons of the ascending and descending tracts Divided into dorsal, lateral, and ventral columns

What is the function of Merkel's discs?

Continuous touch

Stroke Diagnosis

Contrast CT - if bleeding is ruled out by CT, ischemic stroke is assumed & TPA can be given. ASA is an alternative if TPA cannot be given

Corticospinal tract travels from where to where and what type of pathway is it?

Cortex to spine Motor pathway

Most important motor pathway

Corticospinal tract

SLE treatment

Corticosteriods NSAIDs Immunosppressents Antimalarials

Symptoms of myasthenia gravis

Diplopia, ptosis Bulbar muscle weakness (muscles of mouth and throat) Dysphagia, dysarthria, difficulty handling saliva Dyspnea with exertion Proximal muscle weakness

DMD association w/ MH

DMD is associated w/ MH-like syndrome Its really rhabdomyolysis - any cardiac arrest on induction of a DMD pt should be considered to have severe hyperkalemia. Dantrolene does not treat this d/o. They have a normal ryanodine receptor. Succ and volatile anesthetics can trigger this syndrome.

Inside the femoral triangle, the femoral n. runs _________________ to the inguinal ligament.

DEEP

Carbidopa

Decarboxylase inhibitor Prevents levodopa metabolism in the blood, so more levodopa can enter the CNS

Epidural blood patch

Definitive treatment 90% success rate 10 to 20 mls of sterile venous blood Side effects: back ache and radicular pain

Cardiac changes in Duchenne

Degeneration of cardiac muscle (reduces contractility, papillary muscle dysfunction, causes MR, cardiomyopathy, and CHF) Signs of cardiomyopathy: Resting tachy, JVD, S3/S4, displacement of the point of maximal impulse *gold standard cardiac eval is echo

*Hydrophilic* Opioids: Onset

Delayed (30 - 60 min) *meperidine, hydromorphone, morphine

Eaton-Lambert syndrome

Disorder of the NMJ that results in skeletal muscle weakness d/t destruction of the presynaptic voltage-gated calcium channel, reducing the amount of ACh that is released into the synaptic cleft

Area where the nerve stimulator should be placed to elicit contraction of the adductor pollicis muscle?

Distal electrode is placed over the proximal flexor crease of the wrist and the proximal electrode is placed over the flexor carpi tendon.

Most sensitive indicator of MH

EtCO2 rise (out of proportion to minute ventilation)

Most sensitive indicator of MH

ETCO2 that rises out of proportion to minute ventilation

Reconstitution of Dantrolene

Each vial contains 20mg of Dantrolene + 3g Mannitol reconstituted w/ 60mL sterile water (Do not use normal saline, it takes longer to dissolve)

*Hydrophilic* Opioids: Respiratory depression

Early ( < 6 hrs) Late ( > 6 hrs)

Factors that DO NOT increase the risk of TNS

Early ambulation, LA concentration, baricity, glucose concentration

*Lipophilic* Opioids: Respiratory depression

Early only

Hydrophilic opioids respiratory depression

Early: less than six hours Late: 6 to 12 hours

Side by side compare Eaton-Lambert to Myasthenia Gravis

Eaton Lambert: Ca+Channel effected- presynaptic Decreased Ach release Presynaptic neuron Small-cell lung carcinoma (oat cell) Sensitive to Nodepolarizers and Succs AchE inhibitors are not effective Myasthenia Gravis: Postsynaptic Nm receptors effected Decreased response to Ach Postsynaptic motor endplate is effected Thyoma Sensitive to Nondepolarizers Resistant to Succs AchE inhibitors adequate

An epidural hematoma should be evacuated within

Eight hours

Percentages of oxygen utilization in the brain

Electrical activity = 60% Cellular integrity = 40%

Antidromic AVNRT(widened QRS) results when

Electrical impulse travels via the accessory pathway

Filum Terminale

Extends conus medullaris to coccyx

filum terminale

Extends from the conus medullaris to the coccyx

Radial nerve movement

Extension at elbow Supination of forearm Extension of wrist and fingers

What is the most common cause of central retinal artery occlusion?

External compression on the globe from improper head positioning in prone position- reduces venous outflow, increases intraocular pressure, impedes retinal perfusion

Absence of dystrophin allows for: What does the above predispose patients to when given succinylcholine?

Extrajunctional receptors to populate the sarcolemma Hyperkalemia (succs does have the BB warning of sudden cardiac arrest/death in kids with undiagnosed Skmuscle myopathy)

What are all other motor pathways outside of the corticospinal tract known collectively as?

Extrapyramidal tract - these fibers do not pass through the pyramids

Components of GCS

Eye opening (1-4) Motor response (1-6) Verbal response (1-5)

T/F: adding lidocaine jelly to the cystoscope or Foley catheter will prevent autonomic hyperreflexia

FALSE

Warfarin can be reversed with...

FFP, Prothrombin Complex Concentrate, or recombinant factor VIIa

Cranial Nerve VII -Nerve name (5 branches) -Function -Bedside test

Facial (temporal, zygomatic, buccal, mandibular, cervical) Both Facial movement Eyelid closing Taste anterior 2/3 of tongue *Two zebras bit my carrot *Two zits by my clavicle

What are (2) appropriate treatments for a patient with von willebrands disease?

Factor 8 concentrate Desmopressin

Factors that increase the risk of MH

Families from Wisconsin, Nebraska, West Virginia, and Michigan Male Youth

All are associated with apoptosis in the developing brain except (ketamine, fentanyl, midazolam, sevoflurane)

Fentanyl

Select (2) best agents for the neonate with necrotizing enterocolitis

Fentanyl Ketamine Better options than VA and propofol

Preparations for MH patient

Flush machine w/ high flow O2: 20-100min Replace all external components: circuit, CO2 absorbent, breathing bag Remove vaporizers Monitor in PACU for 1-4 hours

What are better headrest options to avoid central retinal artery occlusion?

Foam pillow with cut outs around eyes or mayfield pins

Boundaries of the epidural space

Foramen magnum Sacralcoccygeal ligament Posterior longitudinal ligament vertebral pedicles Ligamentum flavum Vertebral lamina

The Dura matter begins and ends at:

Foramen magnum dural sac

Oligodendrocytes function

Form the myelin sheath in the CNS

C8 sensory innervation

Fourth and fifth digits

Factors that increase the risk of MH

Geography (Wisconsin, Nebraska, West Virginia & Michigan) Male Youth

When is ICP monitoring indicated?

Glasgow coma score </= 7

Global, Cortical and Subcortical cerebral blood flows

Global: 45-55mL/100g tissue/min Cortical: 75-80mL/100g tissue/min Subcortical: 20mL/100g/tissue/min

Cranial Nerve IX -Nerve name -Function -Bedside test

Glossopharyngeal Both Somatic sensation and taste to posterior 1/3 tongue

Meds to avoid w/ hypokalemic periodic paralysis

Glucose containing solutions Potassium wasting diuretics Beta-2 agonist

Meds that are safe w/ hyperkalemic periodic paralysis

Glucose containing solutions Potassium wasting diuretics Beta-2 agonist NDNMB's Acetazolamide

During cerebral hypoxia _______ is converted to lactic acid.

Glucose converts to lactic acid- cerebral acidosis destroys brain tissue. *This is why you dont want hyperglycemia

Risk factors for a CVA

HTN (most important) Smoking, DM, HLD, excessive alcohol, elevated homocysteine level (amino acid from meat)

BP during stroke

HTN is common after ischemic stroke Hypotension decreases CPP and worsen ischemia target pressure should maintained under 185/110

clearance is inversely proportional to (2)

Half-life concentration in the central compartment

It is possible for _____ and ____ to initiate MH like syndrome in the patient with duchenne muscular dystrophy.

Halogenated agents and succs- so avoid them in DMD

What are the only 2 classes of drugs that trigger MH?

Halogenated anesthetics and Succs

Which agents increase beta amyloid production?

Halothane and isoflurane

What is the definitive test for MH

Halothane contracture test

Definitive test for diagnosis of MH

Halothane contracture test high sensitivity and low specificity

Dantrolene MOA

Halts Ca+ release from the RyR1 receptor Prevents Ca+ entry into the myocyte

S/sx of intracranial hypertension

Headache N/V Papilledema - optic nerve swelling Focal neurologic deficit Decreased LOC Seizure Coma

Are the nerves for the infraclavicular block hyper or hypoechoic

Hyperechoic (they are hypoechoic for scalene and supraclavicular)

cranial nerves

I. Olfactory II. Optic III. Oculomotor IV. Trochlear V. Trigeminal VI. Abducens VII. Facial VIII. Vestibulocochlear IX. Glossopharyngeal X. Vagus XI. Accessory XII. Hypoglossal

What increases as a result of pneumoperitoneum during laparoscopic surgery (3)

ICP+CPP A-a gradient - as a function of decreased FRC and V/Q mismatch MAP- due to hypercarbia, the neuroendocrine respone(catecholamines, vasopressin, cortisol) and increased afterload

Parasympathetic output is carried by which cranial nerves?

III, VII, IX, and X

Respiratory affects of Neuraxial anesthesia

Impairment of intercostal muscles (inspiration & expiration) Impaired abdominal muscles (cough, clear secretions) Reduced accessory muscle function Loss of proprioception input from the chest can cause dyspnea Apnea is usually the cause of cerebral hypoperfusion NOT phrenic nerve paralysis

Where do pain neurons synapse?

In the substantia gelatinosa in laminae II and III

Prep options to clean back? Most effective? Caution with:

Iodine, alcohol, chlorhexadine Most effective- alcohol with chlorhexdine Caution: Chlorhexidine is neurotoxic- needs to dry before puncturing skin

First order neurons of the dorsal column ascend the spinal cord on which side?

Ipsilateral - the same side that it entered

Which type of CVA is most common?

Ischemic

Most common cause of vision loss in the perioperative period

Ischemic optic neuropathy

Relative tonicity of CSF compared to plasma

Isotonic (CSF is isotonic with plasma, it is not an ultrafiltrate of plasma and has its own chemical composition) -Osmolarity the same 295 mOsm/L

How does metabolic acidosis effect CBF

It has no effect because H+ cannot pass BBB (only CO2), so respiratory acidosis increases CBF

Conditions that impair venous drainage

Jugular compression secondary to improper head positioning Increased intrathoracic pressure secondary to coughing or PEEP Vena cava thrombosis Vena cava syndrome

At what point does the *femoral n.* divide into anterior and posterior branches?

Just after it passes under the inguinal ligament

Where do the roots turn into trunks?

Just beyond the *lateral border* of the *scalene muscles*

Which IV agent should be avoided in a patient with a history of seizures?

Ketamine

IV agents to avoid in patient w/ history of seizures

Ketamine* (most important) Etomidate, Methohexital, Alfentanil increase EEG activity and can be used for cortical mapping Propofol has been implicated in seizures but it is still a first line drug for seizure activity

ADULT Conus Medullaris

L1 - L2

Area of myocardium most susceptible to myocardial ischemia

LV subendocardium

The dorsal column contains what kind of fibers?

Large, myelinated, rapidly conducting fibers

Scoliosis Definition -Kyphoscoliosis Definition

Lateral and rotational curvature of the spine and ribcage -Posterior curvature of the spinal column

Most common causes of acute spinal cord injury

MVC, fall, assault, sports injury.

Archeocerebellum function

Maintains equilibrium -Structure of cerebellum "architecture needs equilibrium"

Patient risk factors for ION

Male, obese, diabetes, HTN, smoking, old age, atherosclerosis

What is the recommended mA of nerve stimulation?

Many authors recommend a current of 0.2-0.5 mA as an end goal.

PaCO2 levels at which maximal vasodilation and vasoconstriction occur

Maximal vasodilation -> PaCO2 80-100mmHg Maximal vasoconstriction -> PaCO2 25mmHg

Changes in anesthetic management for a patient with Parkinson's undergoing deep brain stimulation

May want to hold levodopa, which worsens symptoms and facilitates optimal electrode placement

The Dorsal column medial leminiscal system transmits what?

Mechanoreceptive sensations: fine touch, proprioception, vibration, fine pressure

A Delta peripheral nerve fibers

Media myelination Function: fast pain, touch, temperature Diameter: 2 to 5 µm Velocity: Sub medium Block onset: Third

This cord gives off a branch of the median nerve and ends as the ulnar

Medial cord

Which column transmits sensory information faster: dorsal medial lemniscal or anterolateral (spinothalamic tract)?

Medial lemniscal (dorsal)

Which opioid can cause seizures

Meperidine d/t its metabolite normeperidine

Where do third order neurons of the anterolateral system synapse? -Tactile signals -Pain fibers

Most tactile signals are relayed to the ventrobasal complex of the thalamus Fibers pass through internal capsule and advance toward somatosensory cortex in the post central gyrus in the parietal lobe -Pain fibers synapse in the RAS--> connections to the thalamus

Anterior nerve root carry:

Motor and autonomic function

Normal muscle coordination neural pathway

Motor cortex sends impulse to basal ganglia and cerebellum Basal ganglia and cerebellum send info to cortex by way of thalamus this feedback loop dependent on relative concentrations of dopamine and ach

Musculocutaneous innervation

Motor of arm Sensory of lateral forearm and wrist

The *femoral n.* MOTOR innervation Anterior and Posterior Sensory innervation

Motor: Anterior branch - sartorius Posterior branch - quads Sensory: Anterior thigh

Most of the CNS neurons are what type?

Multipolar

What are the 3 types of neurons found in the CNS?

Multipolar Pseudounipolar Bipolar

What is dantrolene classified as? Most common side effects of dantrolene

Muscle relaxant Muscle weakness and venous irritation

TNS treatment

NSAIDs opioids trigger point injections

What do you see on the out of plane approach?

Needle is at best seen only in cross section. More commonly, tissue movement is seen as the needle approaches the target.. [If you're going towards the probe perpendicularly, it's OUT of plane, if you're going Parallel to the probe, it's IN PLANE. This is JUST for needle insertion]

What ligaments are penetrated with the paramedian approach to the epidural space?

Needle will pass through 1 ligament: Ligamentum flavum

What ligaments are penetrated with the midline approach to the epidural space?

Needle will pass through 3 ligaments: Supraspinous Interspinous Ligamentum flavum

Renal complications of SLE

Nephritis w/ proteinuria

Renal complications of SLE

Nephritis with proteinuria

What does NAVEL stand for?

Nerve, Artery, Vein, empty space, Lymphatics. Nerves are ALWAYS the most lateral!!!

Axillary approach?

Nerves anesthetized around axillary artery where they have regrouped into terminal branches Straddle the pulse between your two fingers; go above artery; insert 1-2cm

T4 sensory innervation

Nipple line

Cranial Nerves

Oh, Oh, Oh, To, Touch, And, Feel, A, Girls, Vagina, Ah Heaven A - auditory vestibular nerve

Factors w/ lower risk of PDPH

Older age Male Non-cutting tip needle Smaller diameter needle Fluid for LOR syringe Needle parallel to long axis of meninges Continuous spinal catheter (if placed after wet tap)

Cranial Nerve I -Nerve name -Function -Bedside test

Olfactory Sensory Smell

Cranial Nerve Pneumonic

On Old Olympus Towering Top, A Fin and German Viewed A Hopp

HIGHER Risk Factors for PDPH

Patient Factors - young - pregnant - female Provider Factors - cutting-point tip needle - big diameter needle - multiple dural punctures - using air for Loss of resistance - needle perpendic to long axis of meninges

Absolute contraindication to neuraxial anesthesia

Patient refusal

When performing an epidural blood patch, how do you know when it is working?

Patient senses pressure in legs, buttocks, or back

Describe the managment of gout (2)

Patients should be liberally hydrate Sodium bicarb enhances uric acid excretion

Unacceptable response to twitch monitor (supraclavicular)

Pectoralis Bicep Deltoid

Unacceptable response to twitch monitor (infraclavicular)

Pectoralis Biceps Deltoid

Non-cutting tip

Pencil tip point: Sprotte, Whitacre, Pencan Rounded bevel tip: Greene

Complications of supraclavicular

Pneumothorax happens most frequently with this approach to brachial plexus blockade Hemothorax Horner's syndrome Phrenic nerve blockade Recurrent Laryngeal block Contraindicated in patients with severe pulmonary disease.

Most common SLE problems

Polyarthritis and dermatitis

Label the brain

Pons Medulla oblongata Midbrain Temporal lobe Hypothalamus Spinal cord Cerebellum Occipital lobe Parietal lobe Parietooccipital sulcus Frontal lobe Central sulcus Thalamus Corpus callosum Lateral ventricle

What, in the brainstem, causes autonomic integration?

Pons and medulla

The *saphenous n.* block is useful when combined with waht other 2 blocks?

Popliteal block or Ankle block (these do not capture the saphenous n. distribution)

The *saphenous n.* block is useful when combined with what other 2 blocks?

Popliteal block or Ankle block (these do not capture the saphenous n. distribution)

Situations that exacerbate MG symptoms

Pregnancy infection electrolyte abnormalities stress aminoglycoside antibiotics (-mycins*gentamycin, neomycin)

Situations that exacerbate myasthenia gravis

Pregnancy Infx Electrolyte abnormalities Surgical & pyschological stress Aminoglycoside abx

Risk factors with difficult mask ventilation (4)

Presence of a beard BMI >26 lack of teeth history of snoring

*Sacral Plexus* Primary Nerves

Post. femoral cut. n. Sciatic n.

The dorsal column is perfused by which blood supply?

Posterior blood supply (touch and proprioception are spared)

This cord gives off the axillary nerve and ends as the radial

Posterior cord

What do SSEP's test?

Posterior cord Posterior spinal arteries Sensory function *does not monitor motor function

Anterior border of the epidural space

Posterior longitudinal ligament

The *posterior femoral cutaneous n.* provides SENSORY innervation to ___________.

Posterior thigh

Where is the *sural n.* blocked?

Posterior to the lateral malleolus

Where is the *posterior tibial n.* blocked?

Posterior to the medial malleolus

Where is the *posterior tibial n.* blocked?

Posterior to the medial malleolus (bump on medial ankle)

Ventral corticospinal tract is responsible for:

Posture motor

How should you dose nondepolarizers in a patient with MG?

Potency is increased (increased sensitivity) Reduce dose by 1/2 to 2/3

Levodopa

Precursor to dopamine Metabolized to dopamine in circulation - does not penetrate the CNS

Factors that can cause SLE exacerbation

Pregnancy Stress Infection Surgery

While propofol is a first line tx for seizure control, it can rarely cause:

Propofol induced seizures and opisthotonos (rigid posture with arched back)

Acute treatment of a grand mal seizure: Surgical treatment:

Propofol, diazepam, thiopental Surgical: Vagal nerve stimulator/ resection of foci

What is the function of Ruffini's endings?

Proprioception and prolonged touch and pressure

Astrocytes

Provide structural and metabolic support for neurons. Most abundant type of cell in CNS Repair neurons after injury

What is the primary function of Circle of Willis?

Provides redundancy of blood flow in brain.

Which cuff do you inflate first for bier block?

Proximal

Which muscles are most affected in Eaton-Lambert syndrome?

Proximal

With an open repair of an aneurysm, where is the clamp placed and why?

Proximal feeder vessel- placed there to reduce transmural pressure/ risk of rupture while eliminating the need for controlled hypotension *some surgeons don't use clamps may request controlled hypotension- most significant risk is decreased CPP

What is the most common side effects of neuraxial opioids

Pruritus More common in OB patients Stimulation of opiate receptors in the trigeminal nucleus Treat with naloxone

Which lower extremity nerve block has the highest rate of complications?

Psoas compartment block

Brachial plexus - medial to lateral

Randy Travis Drinks Cold Beer Roots Trunks Divisions Cords Branches

Site of absorption of CSF

Reabsorbed into venous circulation via arachnoid villi in the superior sagittal sinus

If a patient requires >20mg/kg of dantrolene:

Reconsider the dx of MH

All inhalational agents are capable of producing seizures, however they they tend to reduce _____ activity in a __________

Reduce EEG activity in a dose dependent way.

Alzheimer's pathophysiology

Reduced ACh, Beta Amyloid Plaques, Neurofibrillary Tangles These cause: Dysfunctional synaptic transmission & Apoptosis Degeneration of Neurons: Early hippocampus/memory; Late cerebral cortex/speech/reasoning

Diagnosis of Parkinson's requires 2 of the 4 cardinal signs:

Resting "pill rolling" tremor Skeletal muscle rigidity Postural instability - loss of balance with altered gait Bradykinesia - slow movement and reflexes

Early respiratory complication of scoliosis

Restrictive ventilatory defect -↓FEV1 & FRC -normal FEV1/FVC ratio Decreased lung volumes: VC, TLC, RV, FRC Decreased chest wall compliance

Pulmonary complications of SLE

Restrictive ventilatory defect Pulmonary hypertension Interstitial lung disease w/ impaired diffusing capacity Pleural effusion Recurrent pulmonary emboli

Where are bipolar neurons found?

Retina and ear You have 2 eyes and 2 ears

Anesthetic considerations for Eaton-Lambert syndrome

Reversal with anticholinesterases may be inadequate even with proper dosing High risk for postop ventilatory failure

Laboratory findings w/ RA

Rheumatoid factor ↑C-reactive protein ↑erythrocyte sedimentation rate

What is the only drug that reduces mortality with ALS?

Riluzole, an NMDA receptor antagonist

interscalene block level

Root level

Which level is the interscalene block?

Root level- most proximal of the brachial plexus

What are the 5 main components of the brachial plexus? The roots arise from C___ to T____

Roots = 5 Trunks = 3 Divisions = 6 Cords = 3 Branches = 5 Reach To Drink Cold Beer *roots arise from C5-T1

In a male patient, what is the next step after the tip of the double lumen ETT passes through the vocal cords?

Rotate the DLT 90 degrees in the direction of the bronchus to be intubated

*Lipophilic* Opioids: How long do they stay in CSF?

SHORTER period of time vs. hydrophilic

Neuraxial recommendations w/ unfractionated heparin

SQ: Proceed w/ block if pt is not on any other blood thinners and has normal clotting mechanisms IV: b/f block hold for 2-4 h after block hold for 1h b/f catheter removal hold for 2-4h

Sacral Hiatus -Coincides with __ -Results from... -Covered by ___ ligament -Significance

Sacral Hiatus -Coincides with S5 -Results from incomplete fusion of the laminae at S5 and sometimes S4 -Covered by sacrococcygeal ligament (punctured with caudal approach) -Provides entry point to the epidural space

*Pediatric* caudal anesthetic doses: (mL/kg)

Sacral: 0.5 mL/kg Sacral-low thoracic (T10) - 1mL/kg Sacral-mid thoracic - 1.25mL/kg

Caudal dosing Pediatric

Sacral: 0.5 mL/kilograms Sacral to low thoracic T10: 1 ML/kilogram Don't Exceed 2.5 mg per kilogram Of bupivacaine, levobupivacaine, Ropivacaine

*Adult* caudal anesthetic doses: (mL)

Sacral: 12 - 15mL Sacral-low thoracic (T10): 20 - 30mL Sacral-mid thoracic: N/A

Caudal dosing adult

Sacral: 12 to 15 ML's Sacral to low thoracic T10: 20 to 30 ML's

Caudal border of the epidural space

Sacrococcygeal ligament

*Lumbar Plexus* At the Ankle

Saphenous n.

Physiologic changes that are MOST likely to occur during autonomic hyperreflexia (2)

Seizures Pulmonary edema (acute rise in SVR can precipitate LV failure, and cause pulmonary edema) HTN bradycardia

Abrupt withdrawal of GABA can cause:

Seizures if pt has hx of seizures - taper for at least 1 week

myastehnia gravis: _______________ to Roc/Vec

Sensitive b/c there is reduced Ach nicotinic receptors at the NMJ -reduce dose by 1/3-2/3

Anesthetic mgmt Eaton-Lambert Syndrome

Sensitive to Succ and NDNMBs - reduce doses Volatile anesthetics are usually enough w/out NMBs Reversal w/ anticholinesterases may be inadequate despite proper dosing High risk for postop respiratory failure strong correlation to small cell carcinoma (oat cell carcinoma)

Effect of Eaton-Lambert syndrome on NMBDs

Sensitive to both succinylcholine AND nondepolarizers *REDUCE doses EL↓S

Patients with MG will be sensitive to ________ and resistant to _________

Sensitive to nondepolarizers and resistant to succinylcholine (d/t reduced type-m nicotinic receptors at NMJ)

Posterior nerve root carry:

Sensor information

T4 innervation

Sensory: nipple line Moto/Autonomic: T1-T4 cardiac accelerator fibers

What is the function of the BBB

Separates the CSF from the plasma -via tight junctions -does not have carrier proteins -poorly developed in neonates

What lab value is increased in patients with osteogenesis imperfecta?

Serum thyroxine (in >50% of patients) *Increased BMR and VO2 -> hyperthermia *Risk for MH is NOT increased

Type of fibers in the anterolateral system

Smaller, myelinated, slower conducting fibers compared to the dorsal medial leminiscal

Which electrolytes are similar between CSF and plasma?

Sodium Bicarb Chloride (119 in CSF vs 102 in plasma) PaCO2 (47 in CSF vs 40)

Method of correcting lactic acidosis with MH

Sodium bicarb 1-2mEq/kg

Which part of the neuron integrates the signal and has the cellular machinery?

Soma

What are the functions of each cranial nerve?

Some Say Marry Money But My Brother Says Big Brains Matter Most Sensory, Motor, Both

What kind of paralysis results from injury to an upper motor neuron? Why?

Spastic and hyperreflexia -Inhibitory impulses from the brain are blocked at the level of the injury which causes over activity of lower motor neurons

What is the plica mediana dorsalis? What is its significance?

Speculative band of connective tissue between ligamentum flavum + dura mater If it exists, it could create barrier impacting spread of meds w/in epidural space Potential culprit of difficult epidural insertion + unilateral EPD blocks *it's very existence is controversial

Absolute contraindications to caudal anesthesia

Spina bifida Meningomyelocele of the sacrum Meningitis

Cranial Nerve XI -Nerve name -Function -Bedside test

Spinal accessory Motor Shoulder shrug

conus medullaris

Spinal cord and at L1-L2 in adults L3 In infants

How does spinal anesthesia cause drowsiness?

Spinal reduces sensory input to the reticular activating system which can cause drowsiness

Most common cause of ION

Spinal surgery in the prone position can also occur after radical neck dissection or CPB

ION is most common after what type of surgery?

Spine surgery in the prone position can also occur after CPB and radical neck dissection

Spinothalmic tract travels from where to where and what type of pathway?

Spine to thalamus Sensory

Tract of Lissauer is part of the:

Spinothalamic tract (anterolateral)

Pencil point tip Needles

Sprotte Whitacre Pencan Pros: -lower risk of post dural puncture headache -More tactile feel -Needlee likely to deflect -Less likely to injure cauda equina Cons: requires more force

*Interscalene block* Landmarks Image

Sternocleidomastoid muscle- accentuate by having pt lift head

Meningismus

Stiff neck Sign of meningitis Occurs as blood spreads throughout and irritates the subarachnoid space

What is the goal of spinal fusion with instrumentation for scoliosis patients?

Stop the progression of the curvature and prevent further deterioration of cardiopulmonary function

Lipophilic opioids

Sufentanil Fentanyl Substantial gelatinosa Rexed lamina II & III Fast onset,short duration More systemic absorption Early respiratory depression Lower incidence of nausea vomiting pruritus

At the level of the ankle, which nerve is not immediately adjacent to a vascular structure?

Superficial peroneal nerve *LEAST likely to result in intravascular injection

Bier block technique

Supine position Place double cuff proximal, IV distal Elevate extremity and exsanguinate with esmarch bandage Inflate proximal tourniquet Inject LA 40 to 50cc of .5% Lido for arm and 100cc of .25% Lido for leg Inject slowly over 90 sec Produce effects in 5 mins After 45 min inflate distal tourniquet and then deflate proximal

Technique for the Infraclavicular Block

Supine, head opposite direction, ipsilateral arm 90 degrees Needle: 22g, 10 cm Insert @ 45 degree angle Brachial plexus stimulation is usually elicited between 5-8 cm 30-40 cc local

Functions of the glial cells (nerve glue) (4)

Support neuronal function by: -Creating a healthy ionic environment -Modulate nerve conduction -Controlling reuptake of neurotransmitters -Repairing neurons following neuronal injury

What is the treatment for CES?

Supportive

Which BP block is most likely to cause a *pneumothorax*? Why?

Supraclavicular block - the cupola of lung is just medial to 1st rib (higher on R side) - tall, thin pts at higher risk for ptx - consider PTX if pt coughs/complains of CP during needle insertion/manipulation

What is intracranial pressure?

Supratentorial CSF pressure

Pathophysiology of MH

T-Tuble is depolarized, extra cellular Ca+2 enters myocyte via dihydropyridine receptor which activates defective RyR1 receptor instructs the SR to release too much calcium into the cell More calcium is available to engage with contractile elements, so more is attempted to be returned via SERCA2, which consumes a lot of ATP creating increased O2 consumption and CO2 production

Where do most cerebral aneurysms arise from?

The circle of Willis

Where do you want to place the needle with a supraclavicular block?

The goal is to place the needle in the brachial plexus sheath in the vicinity of the subclavian artery and inject local anesthetic.

What is the exception in Sensory innervation of the UE?

The hand

Where does ALS often begin?

The hands - over time weakness spreads to the rest of the body: tongue, pharynx, larynx, chest

Which block has been associated with inevitable phrenic involvement and consequent hemidiaphragmatic paresis or paralysis?

The interscalene level brachial plexus block

What is above (superior) to the axillary artery?

The median nerve

Hypdrophilic vs lipophilic opioid profiles

The more hydrophilic a drug is the more likely it is to stay in the subarachnoid space and ascend toward the brain. The more lipophilic a drug is the more likely it is to diffuse into the systemic circulation

Which nerve do you miss with an axillary block?

The musculocutaneous

How can a pneumothorax develop during an inter-scalene block? Which side is at greater risk?

The needle can be too caudal -Right lung is at greater risk bc the cupola of the lung is higher on that side -sx: pt coughing and c/o chest pain during needle insertion/manipulation

If one side of the circle of wills becomes occluded then...

The other side should be able to perfuse the affected areas of the brain. * only holds true in 42-52% of the population- though there is ususally additional networks that provide redundancy

The transverse processes projects ___, while the spinous process projects ___. Muscular attachment to these regions provides stability and support. The spinous process also serves as a landmark to determine ___.

The transverse processes projects laterally, while the spinous process projects posteriorly. Muscular attachment to these regions provides stability and support. The spinous process also serves as a landmark to determine midline.

Why do hydrophilic drugs cause late respiratory depression?

They ascend rostrally where they can inhibit the respiratory center late phase is 6-12h

How do local anesthetics cause their effect in epidural anesthesia

They need to diffuse through the dura cuff before they can block the nerve roots -can also leak through intervertebral foramen to enter the paravertebral area

What are anesthetic goals for aneurysms? What do you do if aneurysm ruptures during induction?

Tight BP control during induction/intubation Reduce ICP and start cerebral protection methods

Tonic vs. clonic movements

Tonic = whole body rigidity Clonic = repetitive jerking motions

The axons form what kind of matter?

White matter d/t myelin

Hypokalemic periodic paralysis is present if skeletal muscle weakness follows...

a glucose-insulin infusion (weakness occurs after serum potassium is reduced)

Match the Intrinsic Laryngeal Muscle with its action on layrngeal movement? a)Aryepiglottic b)cricothyroid c)posterior cricoarytenoid d)thyroarytenoid

a)Aryepiglottic - closes glottic opening b)cricothyroid - lengthens vocal cords c)posterior cricoarytenoid - abducts vocal cords d)thyroarytenoid - adducts vocal cords

What is achieved with supraclavicular block?

achieves excellent anesthesia to the entire arm, including the hand (may still miss the ulnar nerve)

Why do neuraxial opioids cause N/V?

activation of opioid receptors in the area postrema of the medulla and in the vestibular apparatus

In DMD Ca+ can freely enter the cell causing what?

activation of proteases that destroy the contractile elements causing inflammation, fibrosis, cell death

Aldrete Score examines 5 variables

activity respiration circulation consciousness oxygen saturation

Familial Periodic Paralysis

acute episodes of acute skeletal muscle weakness, accompanied by changes in serum potassium concentration -dx is in the muscle tissue not the NMJ Hypokalemic = Ca+ ch problems Hyperkalemic periodic paralysis = Na+ ch problems

Guillain-Barre is also called...

acute idiopathic polyneuritis

Conus meddularis location

adult: L1-L2 Infant: L3

Bronchial blockers (3)

allow the isolated lung to be suctioned can be used if the patient requires nasotracheal intubation can be used for lung separation in the patient with a tracheostomy

How does clonidine affect LA?

alpha 2 agonist, weak local anesthetic. But act synergistic with with local anesthetic so it prolongs anesthesia/analgesia. produces sedation.

Which option initiates hypoxic pulmonary vasoconstriction?

alveolar hypoxia

What are intercostal blocks used for?

analgesia

Surgical treatment for SAH

aneurysm clipping or endovascular coiling surgical repair should take place 24-48 hours after initial bleed

intercostal brachial nerve

arises from T2 = not covered in a brachial plexus block Field block is required to anesthetize this nerve = block may help awake pt tolerate UE tourniquet

body movement associated w/ perctoralis twitch response

arm adduction

Guillain-Barre syndrome

ascending paralysis/muscle weakness that is preceded by influenza like illness

Airway complication of RA

atlantoaxial subluxation and separation of the atlanto-odontoid articulation Cause: weakening of the transverse axial ligament -> allows the odontoid to directly compress the spinal cord at the level of the foramen magnum -> risk for quadriparesis & paralysis

Duchenne presents with...

atrophy and painless muscle degeneration Progressive deterioration of skeletal muscle strength culminating in profound weakness (these pts often req surgical correction of scoliosis/contractures and rarely live past 30y)

Bradycardia treatment

atropine or glycopyrrolate

Temporal lobe

auditory cortex and language

Guillain-Barre pathophysiology

autoimmune attack on peripheral myelin - loss of AP conduction lasts 2-4 weeks

rheumatoid arthritis (RA)

autoimmune d/o of the synovial joints

systemic lupus erythematosus (SLE)

autoimmune disease characterized proliferation antinuclear antibodies Mostly women Does not involve the spine Butterfly rash

Nerve associated w/ deltoid twitch response

axillary

Which block is preferred for OP procedures?

axillary approach.

Axillary Block Ultrasound Image- what is the landmark to look for?

axillary artery

Best block for hand surgery?

axillary block.

Factors that affect spread of spinal anesthesia

baricity patient position does Site Volume of CSF Density of CSF

PDPH treatment

bed rest Hydration NSAIDs caffeine Epidural blood patch Sphenopalantine ganglion block

Upper motor neuron (corticospinal tract)

begin in the cerebral cortex and end in the ventral horn -cell body originates in the cortex

dura mater borders

begins at foramen magnum and ends at the dural sac

paravertebral

beside the vertebrae

When comparing dexmedetomidine to propofol for MAC, which statements better describe dexmedetomidine? (3)

better analgesia inferior amnesia longer onset

Respiratory depression caused by: Hydrophilic opioids: cause a ______ respiratory depression. Early phase results from_____ _______. Late phase resp depress results from opioid tendency to _________ to the _____ where they can inhibit resp center. When does the early phase occur? When does the late phase occur?

biphasic resp depression; early phase results from systemic absorption Late phase results from opioid tendency to ascend to the brain where they inhibit respiratory center Early phase occurs <6h Late phase 6-12h

What does air look like on a US?

black (hypoechoic)

Causes of Neuraxial bradycardia

blockade of T1-T4 -> relative increase of pSNS tone Unloading ventricular mechanoreceptors->Bezold-Jarisch reflex Unloading of the stretch receptors in the SA node

Bradycardia is caused by:

blockade of preganglionic cardioaccelerator fibers T1-T4 increase in parasympathetic tone unloading of ventricular mechanoreceptors----> Bezold-Jarisch reflex unloading of the stretch receptors in the SA node

Sacral cornu

bony nodules that flanks the sacral hiatus

What axis is best when placing an A-line?

both -When placing A-line: short axis to stick the artery and then switch to long axis to see if you're threading the artery correctly.

osteogenesis imperfecta

brittle bone disease = connective tissue d/o Possible difficult airway = c-spine precautions, cervical range of motion Kyphoscoliosis -> restrictive lung dx -> V/Q mismatch Blue sclera Increased serum thyroxine

How is the brachial plexus formed?

by the union of C5 - T1 with some minor contributions by C4 and T2 -As they exit the intervertebral foramina, they converge and form: trunks, divisions, cords and terminal nerves (musculocutaneous, median, radial, ulnar)

What are landmarks for the supraclavicular block?

clavicle, subclavian pulse -find pulse and go 2cm below.

When used during laparoscopic procedure, an LMA:

can be used if the procedure is less than 15minutes

hyperbaric trendelenberg

can cause high spinal before block is set Usually levels off at T4 w/ supine position. Can increase to T1 if put in Trendelenberg

Most common cause of ischemic stroke

cardio-embolitic event = afib

In the geriatric patient, what organ system is the primary cause of risk throughout the perioperative period?

cardiovascular

Cervical and thoracic spinal processes angle in the _____________ direction

caudal Requires more cephalad approach with needle

Radial nerve injury is caused by__ Presents with ___

caused by external pressure at the spiral groove of the humerus presents with wrist drop

Hyponatremia during aneurysm surgery is most commonly the result of...

cerebral salt-wasting syndrome- not SIADH

Hemodynamic instability (neurogenic shock) is greatest with injuries to ...

cervical or upper thoracic cord -the higher the injury, the greater degree of hemodynamic instability

Initial anesthetic considerations w/ TBI

cervical spine stabilization airway protection optimization of hemodynamics cerebral protection

vertebral column sections

cervical: C1-7 thoracic: T1-12 lumbar: L1-5 sacrum: S1-5 fused coccyx: 4 fused

cortisol synthesis is dependent on

cholesterol required to produce mineralocorticoids, glucocorticoids, and androgens

About 2% of those affected with Guillain-Barre will develop...

chronic inflammatory demyelinating polyneuropathy

most common site of cerebral aneurysm

circle of willis

where do the anterior and posterior circulation converge

circle of willis = its purpose is to provide redundancy in the blood flow to the brain, so if one part is compromised the other part can provide perfusion

What are the landmarks for supraclavicular block?

clavicle, subclavian artery

Relative contraindications to neuraxial analgesia

coagulopathy, Increased intracranial hemorrhage, sepsis, infection at sight, hypovolemia, valve lesion with fixed stroke volume, Scoliosis, arthritis, spinal fusion, osteoporosis, difficult airway, full stomach, peripheral neuropathy, multiple sclerosis

Cerebral cortex

cognition sensation movement

2 statements about neuraxial anesthesia in the morbidly obese patient

compared to normal weight patient, they are less tolerant of a high block. sitting position is preferred over the lateral position for block placement - improves landmark visibility

LeFort 1 Fracture

cribiform plate remains intact. oral and nasal intubations are safe

2 routes infectious organism can reach the CSF

contaminated needle (breech of aseptic technique) bacteria in patients blood at time of SAB

Most common periop eye complication

corneal abrasion

portions of spinal cord perfused by the anterior blood supply

corticospinal tract (flaccid paralysis) Autonomic motor fibers (bowel & bladder dysfxn) Spinothalamic tract (loss of pain & temp sensation) (touch and proprioception are from the dorsal column supplied by the posterior blood supply)

MS treatment

corticosteroids interferon azathioprine

CMRO2 is ___________ to cerebral blood flow

coupled = the higher the need for oxygen, the more blood will be there to satisfy the need

What is the 2nd messenger of nitric oxide?

cyclic guanosine monophosphate

Eaton-Lambert Syndrome

d/o of the NMJ Antibodies block presynaptic calcium channels which blocks the release of Ach from the presynaptic neuron - IgG mediated destruction post-synaptic Ach receptors are normal

Complete spinal cord injury

damages upper motor neuron -> leads to flaccid paralysis, loss of sensation below the level of the injury, & bowel & bladder dysfxn After acute phase, spinal reflexes return and may lead to spasticity

Epidural anesthesia site of action

diffuse through dural cuff Block nerve roots Leak into intravertebral foramen, cause of paravertebral blocks

lateral corticospinal tract

fibers that innervate the limbs crossover to the contralateral side in the medulla, then descend through the lateral corticospinal tract

20-40 min of bier block

deflate and reinflate

Ulnar nerve block

derived from medial cord of the brachial plexus elbow flexed 90 degrees, injected b/w the olecranon and medial epicondyle

Median nerve block

derived from the lateral and medial cords of the brachial plexus In the antecubital fossa, inject medial to the brachial artery *do not use this block in a patient w/ carpal tunnel syndrome

Radial nerve block

derived from the posterior cord of the brachial plexus inject between the biceps tendon and brachioradialis

Baricity

describes a local anesthetic solution relative to CSF

Cobb angle

describes the magnitude of spinal curvature in scoliosis -2 most displaced vertebrae at the top and bottom are compared

which drugs are least likely to cause postoperative cognitive dysfunction in the elderly? (desflurane, atropine, remifentanil, morphine, midazolam, glycopyrrolate)

desflurane remifentanil glycopyrrolate

First order neuron (Dorsal)

detects a stimulus and transmits a signal to the spinal cord -enters through the dorsal root ganglion -ends in the medulla -Ascends on ipsilateral side (same side it enters on) -Synapses w/ 2nd order neuron in the medulla

C3-5 myotome

diaphragmatic muscle

patient with hx of chronic pain presents with MI. Hx of gastric ulcer and renal impairment. Pt is most likely receiving chronic therapy of: (diclofenac, amitryptyline, oxycodone, imipramine)

diclofenac non-selective cyclooxygenase(COX) inhibitor

Epidural needles

differ by angle of tip Crawford = 0 Hustead = 15 Tuohy = 30

myasthenia gravis s/s

diplopia, ptosis (early signs) Bulbar muscle weakness (muscles of mouth & throat) -> dysphagia, dysarthria, and difficulty handling saliva DOE Proximal muscle weakness

Risk for postop mechanical ventilation in patients with MG is increased with...

disease duration >6 years daily pyridostigmine >750mg/day vital capacity <2.9L COPD median sternotomy> transcervial thymectomy

arterial cerebral circulation

divided into anterior and posterior -> converge at the circle of Willis

Where do the cell bodies of second order neurons of the spinothalmic tract reside?

dorsal horn of spinal cord

Where do sensory neurons enter the spinal cord?

dorsal root

The syndrome associated with Duchenne muscular dystrophy is not true MH, but is instead...

due to rhabdomyolysis, not defective RyR1 receptor Not treatable with dantrolene

Where does the subarachnoid space terminate?

dural sac

Increased risk for postop mechanical ventilation w/ myasthenia gravis

duration > 6 years Daily pyridostigmine > 750mg/day Vital capacity < 2.5L COPD Median sternotomy > transcervical approach

What divide the muscular compartments from potential spaces?

fascial membranes.

Factors that have no effect on PDPH

early ambulation Continuous spinal catheter (if placed after spinal block)

Factors that do not increase the risk of TNS

early ambulation LA concentration Baricity glucose concentration

Infraclavicular indications and landmarks

elbow, forearm, and hand NOT above elbow Landmarks: Coracoid process, clavicle, Axillary artery and vein

Amygdala

emotion appetite responds to pain and stressors

Burn patient with bronchoscopy that reveals grade 3 injury. What is the best intervention

endotracheal intubation

First order neuron (Anterolateral)

enters through dorsal root ganglion Cell body in the dorsal root ganglion Ascends or descends 1-3 levels on the ipsilateral side via Lissauer tract b/f synapsing with the 2nd order neuron Synapses with the 2nd order neuron in the dorsal horn laminae I, IV, V, VI

What is contraindicated with a wrist block

epi solutions

Result of injecting local anesthetic into the subdural space

epidural dose: high spinal spinal dose: failed spinal

major complication of neuraxial anesthesia

epidural hematoma -> compresses the dura -> spinal cord ischemia tx: surgical decompression w/in 8h

intrathecal vs epidural opioid dosing

epidural opioids need to diffuse through the epidural space and the dural cuff so only a fraction reaches the spinal nerve -> need a higher dose

What nerves are covered in a 3-in-1 Block?

femoral n. lateral femorocutaneous n. obturator n.

where is the musculocutaneous nerve found?

found in the fascial layers between biceps and coracobrachialis muscles.

Anterolateral peripheral receptors

free nerve endings nociceptors

grand mal seizure (tonic-clonic seizure)

generalized seizure tonic phase = whole body rigidity clonic phase = jerking movements respiratory arrest -> hypoxia increased brain activity -> ↑CMRO2

Malignant hyperthermia

genetic disease characterized by disordered calcium homeostasis - dysfunctional ryanodine receptor (doesn't turn off, ca+ keeps pumping out) SERCA pump also keeps working. They both use up ATP causing lactic acidosis

Where do most neurologic tumors arise from

glial cells

Region that is anesthetized by the glossopharyngeal nerve block

glossopharyngeal nerve (CN9) innervates the posterior 1/3 of the tongue to the topside of the epiglottis. this includes the vallecula. Services the afferent limb of the gag reflex

laminae

grey matter is subdivided into 9 laminae Laminae I-VI: dorsal grey matter, sensory Laminae VII-IX: ventral grey matter, motor

Area of spinal cord where pain modulation occurs

grey matter of the spinal cord (the butterfly) contains neuronal cell bodies

Familial periodic paralysis

group of diseases characterized by intermittent attacks of skeletal muscle weakness associated w/ hypo or hyper-kalemia

Myotonic Dystrophy

group of diseases where the hallmark is prolonged muscle contracture (myotonia) after a voluntary skeletal muscle movement

What is a tract in the spinal cord?

group of fibers inside the white matter that relay info up/down the spinal cord to/from the brain

Spinal tracts

group of fibers inside the white matter that relay information up and down the spinal cord

Axillary block complications

hematoma (hold pressure for 3-5min) LAST

Valproic Acid (Depakote) s/e

hepatotoxicity thrombocytopenia (surgical bleeding - esp. in kids) Displace phenytoin from plasma proteins

Respiratory depression with opioids is more common with: (6)

hi doses co-admin of sedatives low lipid solubility old age naivety increased intrathoracic pressure

The level of autonomic blockade is _______ than sensory and motor block (Spinal Anesthesia)

higher 2 to 6 dermatones higher than sensory

If ICP is elevated, CPP requires a ______________ MAP to maintain CPP

higher = if MAP is low w/ a high ICP you risk ischemia

Hyperbaric

higher density than CSF - sinks

Risks of cutting needles

higher risk of PDPH less tactile feel Needle more easily deflected More likely to injure cauda equina

Procaine 10% in water is __________ Due to Containing a lot of molecules

hyperbaric

Anesthetic considerations for mastectomy with sentinel node biopsy (2)

hypercalcemia is common - MC metastisis is bone SpO2 may become inaccurate during surgery - if isosulfan blue dye is injected to locate a sentinel node

What do nerve roots look like on a US?

hyperechoic (white)

What increases CMRO2

hyperthermia ketamine N2O (Hyperthermia >42 degrees denatures proteins and destroys neurons)

Physiologic changes associated with acrylic bone cement include

hypotension from cement monomer absorption hypoxemia from air or fat embolism increased PVR cardiac arrest from right HF unexpected LOC during RA

S/S of neurogenic shock

hypotension, bradycardia, hypothermia w/ pink, warm extremities sympathectomy below the injury can last 1-3 weeks

S/S of Hypovolemic shock

hypotension, tachycardia, and cool, clammy extremities

What decreases CMRO2

hypothermia halogenated agents propofol etomidate barbituates

Diagnosis of Hypokalemic periodic paralysis

if muscle weakness follows a glucose-insulin infusion

Diagnosis of Hyperkalemic periodic paralysis

if muscle weakness follows oral potassium administration

Lower motor neuron injury signs/symptoms

impaired reflexes and flaccid paralysis

hypobaric supine

in supine position it rises to lower lumber region in sitting position it rises toward the brain (bad)

Laminae I - VI reside...

in the dorsal grey matter

majority of post-tonsillectomy hemorrhage occur

in the first 6hrs(75%), 24hrs(25%)

What is the most favorable place to find the nerves of the brachial plexus

in the space of the supraclavicular triangle.

Laminae VII - IX reside...

in the ventral grey matter

Masseter muscle spasm is due to...

increased calcium in the myoplasm Site of action is distal to the NMJ, so a NMBD won't relax the jaw

For every 1mmHg increase in PaCO2, CBF...

increases by 1-2mL/100g/min Linear relationship between PaCO2 and CBF

Affect of obesity and pregnancy on epidural space

increases intra-abdominal pressure -> causing engorgement of baston's plexus ->decreases the volume of the epidural space -> increased risk of needle injury of cannulation during neuraxial techniques

Ehlers-Danlos syndrome

inherited disorder of collagen & procollagen — primarily your skin, joints and blood vessel walls. Coagulopathy -> spontaneous bleeding into the joints * AAA Avoid regional anesthesia & IM injections

Charcot-Marie-Tooth disease

inherited peripheral neuropathy. Presents as skeletal muscle weakness and wasting. Usually confined to lower third of legs, but can also affect the quadriceps, hands, forearms

Neurendocrine affects of neuraxial anesthesia

inhibition of afferent traffic from the surgical site diminishes the surgical stress response. ↓circulating catecholamines, renin, angiotensin, glucose, thyroid stimulating hormone, growth hormone

Sphenopalantine ganglion block

inserting two qtips into the posterior wall of the nasopharynx

Where do spinal nerves exit the vertebral column?

intervertebral foramina

how is the epidural space connected to the paravertebral space

intravertebral foramina

When using a spinal needle that is 22g or smaller use an:

introducer needle

Most common cause of periop vision loss

ischemic optic neuropathy (ION) = inadequacy of blood supply to the optic nerve -not associated with pain -occur w/in 24-48h after surgery -caused by external compression of the glob (most common) or embolism (CPB) s/s: cherry red macula with surrounding pale retina

Hyperkalemia treatment

iv calcium gluconate/ chloride insulin and glucose Hyperventilation Beta agonists bicarb lasix

Where does venous blood flow exit the brain

jugular veins

What should be avoided in the patient with myelomeningocele? (lateral, desflurane, succs, latex)

latex

Posterior borders of the epidural space

ligamentum flavum vertebral lamina

Neuraxial opioids effect on the fetus

lipophilic will have greater effect b/c more cross into systemic circulation

What systems are unchanged by neuraxial anesthesia

liver and kidneys

Is a long or short needle used in the Infraclavicular Block?

long

Treatment for vasospasm is aimed at?

maintaining CPP CPP=MAP-ICP or CVP (whichever is higher) -idea is that ischemic areas in brain are already max vasodilated so perfusion to areas are pressure dependent

Duchenne is more common in...

males

Which measures the concentration of anesthetic by bombarding the gas sample with electrons?

mass spectrometry

Absolute indications for single lung ventilation (3)

massive hemorhage unilateral lung lavage control of ventilation of only one lung (bronchopleural fistula(major bronchial trauma

All of the following are displaced by a jaw thrust except

mastoid process is fixed and does not move with the mandible

Why do you see SOB in an interscalene block?

may be due to paralysis of phrenic nerve or may indicate a pneumothorax. Reason why you only do one shoulder at a time

Nerve associated w/ bicep twitch response

musculocutaneous

The *saphenous n.* provides SENSORY innervation to what 2 structures?

medial aspect of knee medial malleolus

Axillary approach to brachial plexus block, blocks what nerves (4)

median ulnar radial musculotaneous NOT the axilary nerve

S/sx alzheimers:

mem loss apraxia aphasia agnosia difficulty speaking and forming words

Hippocampus

memory learning

Hydrophilic opioids

meperidine Hydromorphone Morphine Stays in CSF longer, Wider spread Rostral Substantial gelatinosa Rexed lamina II & III Delayed onset, longer duration Early and late respiratory depression Higher nausea vomiting and pruritus

triad of obesity, htn, and dm2 is known as

metabolic syndrome

Babinski sign

method to test the integrity of the corticospinal tract normal: plantar flexion (downward pointing of toes) abnormal: plantar extension (fanning toes)

Why to use a Tuohy

minimizes the risk of dural puncture

Horner's syndrome consists of what?

miosis, anhydrosis (lack of sweating), ptosis (eye/facial droop), and nasal congestion

characteristics of urinary retention w/ neuraxial opioids

more common in young males more common w/ neuraxial opioids vs other routes caused by inhibition of sacral parasympathetic tone reversed w/ naloxone

Broca's area

motor control of speech

Frontal lobe

motor cortex

Feedback loop implicated in Parkinson's

motor cortex -> basal ganglia & cerebellum -> back to cortex via the thalamus (suppresses the motor cortex)

Acute spinal cord injuries are most often caused by...

motor vehicle accident fall assault sports injury

3 types of neurons

multipolar: most CNS neurons pseudounipolar: dorsal root ganglia, cranial ganglia bipolar: Retina, ear

Lower motor neuron involvement in ALS presents as...

muscle weakness, fasciculations, and atrophy

The BBB is poorly developed in...

neonates

How does a subarachnoid hemorrhage result in death

obstructive hydrocephalus Rebleeding Vasospasm

*When do you use triple H therapy and nimodipine?

only if aneurysm has ruptured

What controls cerebral vascular resistance?

pH of CSF around arterioles

Most common problem w/ Pagets

pain and bone fractures

All venous blood exits the brain via the...

paired jugular veins

Region of the arm that is supplied by the median nerve

palm of hand ventral region of thumb Distal portions of index, middle and medial half of ring finger

If too anterior with interscalene block, what will you see?

phrenic stimulation -need to raise the needle

ANP increases all of the following except: (water excretion, GFR, sodium excretion, plasma volume)

plasma volume facilitates natriuresis by increasing GFR and facilitating sodium and water excretion

Guillane Barre treatment

plasmapheresis &/or IV IgG (Unlike MS - steroids and interferon do not help)

Diagonstic criteria for type 2, but not type 1, complex regional pain syndrome include:

previous nerve injury

ependymal cells

produce cerebrospinal fluid form the choroid plexus - located in all 4 ventricles

amyotrophic lateral sclerosis (ALS)

progressive degeneration of motor neurons in the corticospinal tract Upper and lower motor neurons are affected

Transverse processes

project laterally from the right and left sides of the vertebral arch muscular attachment

spinous process

projects posteriorly Denotes the midline

Myotonic Dystrophy

prolonged contracture after voluntary muscle contracture Cause: dysfunction ca+ sequestration by the sarcoplasmic reticulum Contractures can be so severe they interfere w/ intubation and ventilation

Clinical presentation of Eaton-Lambert

proximal muscles are most affected weakness is worst in the morning and gets better throughout the day weakness of respiratory and diphragm muscles ANS dysfxn cause orthostatic HoTN, slowed gastric motility, urinary retention

The *lumbar plexus* forms posterior to the ________________ and anterior to the __________________.

psoas muscle quadratus lumborum muscle

Secondary signs of Parkinson's

psychosis depression dementia loss of facial expression diaphragmatic spasm oculogyric crisis

Horner's syndrome symptoms

ptosis, myosis, anhydrosis

T12 dermatome

pubic symphysis

how do you check the musculocutaneous nerve and what pt. action will you see?

pull and pt. will flex arm with bicep

how do you check the radial nerve and what pt. action will you see?

push and pt. will extend arm with triceps

Cushings triad

r/t ICP = HTN, bradycardia, irregular respirations

What are the target primary nerves of the axillary block?

radial, median, ulnar (all contained in a neurovascular sheath around the axillary artery) musculocutaneous which is not in the sheath

3 terminal nerves that can be blocked at the forearm or wrist

radial, ulnar, median

The thoracolumbar region of the anterior spinal cord is highly dependent on ______ _______ and interruption of it can cause ______ to the corresponding spinal cord segments

radicular arteries interruption can cause ischemia or infarction

Local anesthetics effect on seizures

reduce the seizure threshold, but regional anesthesia does not increase the risk for seizures

gastric contents in the barrel of the LMA classic. Appropriate next step?

remove the LMA

myastehnia gravis: _______________ to Succ

resistant b/c there is reduced Ach nicotinic receptors at the NMJ -increase RSI dose 1.5-2mg/kg

Main treatment for alzheimer's

restore concentration of Ach cholinersterase inhibitors = increase pSNS tone (can see bradycardia, syncope, N/V) If anticholinergic is need use glyco (does not cross BBB) (prolongs Succ)

Anesthetic mgmt if aneurysm ruptures during procedure

reverse heparinization with protamine lower MAP into low/normal range

SLE Anesthetic Considerations

risk of postextubation laryngeal swelling and airway obstruction (smaller ETT) risk for hypercoaguability & thrombosis (stroke, DVT, PE) Cyclosporine prolongs succ

Robert Taylor Drinks Cold Beer means what?

roots, trunks, divisions, cords, branches

status epilepticus

seizure activity > 30 min or 2 grand mal seizures w/out regaining consciousness in b/w respiratory arrest -> hypoxia increased brain activity -> ↑CMRO2 treatment: phenobarbital, thiopental, phenytoin, benzos, propofol, general anesthesia

intervertebral discs

separate the vertebrae degeneration decreases the size of the intervertebral foramina and can cause nerve compression

Most common cause of death in a patient with LVAD

sepsis

TNS s/s

severe back and butt pain that radiates to both legs develops within 6-36 h and persists for 1-7 days

What agent is most likely to cause a fire inside the breathing circuit?

sevoflurane

Shape of epidural space

shallow anteriorly but deep posteriorly especially in the lumbar region

interscalene block indications & landmarks

shoulder, arm, and elbow surgery Landmarks: Clavicular head of the sternocleidomastoid and cricoid cartilage

Parietal lobe

somatic sensory cortex

The risk of epidural hematoma is _____________ during block placement and catheter removal

similar

isobaric

similar baricity to CSF - stays at injection site

injury above the level of decussation in the medulla

spastic paralysis on the contralateral side of the body

Upper motor neuron involvement in ALS presents as...

spasticity, hyperreflexia, and loss of coordination

Telangiectasia

spider veins in CREST syndrome can cause mucosal bleeding

Absolute Contraindications to Caudal blocks

spina bifida meningomyeloceleof the sacrum Meningitis

Orientation of ___ can differentiate lumbar, thoracic, cervical vertebra

spinous process

autonomic hyperreflexia pathophysiology

stimulation below the level of the SCI -> HTN -> bradycardia -> body attempts to reduce afterload above the level of the injury (hypotension)

Most common source of post-spinal bacterial meningitis

streptococcus viridans

Clinical presentation of Cricoarytenoid arthritis

stridor, hoarseness, dyspnea -> airway obstruction edema or erythema of vocal cords risk for postextubation airway obstruction

dystrophin

structural protein of the cytoskeleton in skeletal and cardiac muscle cells. Helps anchor actin and myosin to the cell membrane Also allows extrajunctional receptors to populate the sarcolemma -> hyperkalemia (this is why people w/ DMD should not get Succ)

The vertebral arteries are branches off the...

subclavian arteries

Technique to decrease the absorption of opthalmic topical local anesthetic into the systemic circulation

tell the patient to keep the eye shut for 1minute increases absorption by the eye and reduces drainage into nasal mucosa

Which drugs show a prolonged effect in the patient with a dibucaine number of 20?

succinylcholine benzocaine 20= atypical homozygous pseudocholinesterase deficiency

Which neuraxial opioid causes the most sedation

sufentanil

Patient has visceral pelvic pain after receiving radiation for rectal cancer. Which procedure is most likely to provide pain relief for this patient

superior hypogastric plexus block superior hypogastric plexus innervates the pelvic organs

Arachnoid villi location

superior sagittal sinus

Trunks

superior: C5-C6 middle: C7 inferior: C8-T1

Cauda equina treatment

supportive

What is one of the easiest blocks to do with US?

supraclavicular block

Neuraxial opioids do not causes:

sympathectomy Skeletal muscle weakness Changes in proprioception

Neuraxial opioids do NOT cause:

sympathectomy skeletal muscle weakness changes in proprioception

GI affect of neuraxial anesthesia

sympathetic inhibition allows unopposed parasympathetic stimulation -> relaxation of sphincters and increased peristasis

Autonomic dysfunction with Guillain-Barre presents as...

tachycardia or bradycardia, HTN or hypotension, diaphoresis or anhidrosis, and orthostatic hypotension

The most common site of transtentorial herniation

temporal uncus - herniation of this area puts pressure on CNIII (oculomotor) and causes blown pupils, reflects pressure on the midbrain

Akinetic seizure

temporary LOC and loss of postural tone -can lead to a fall -> head injury -more common in children

What part of the airway would you expect reynolds number <2000

terminal bronchioles molecules travel parallel center of the tube is fastest, near the walls is the slowest laminar flow

A generalized seizure occurs when...

the activity affects both hemispheres of the brain

The anterior spinal artery perfuses...

the anterior 2/3 of the spinal cord (yellow area)

The Babinski test tests the integrity of...

the corticospinal tract

Effect of PaCO2 on CBF

the pH around arterioles effects their diameter ↑PaCO2 (↓pH) causes vasodilation = for every 1mmHg increase in PaCO2 -> CBF increases 1-2mL/100g tissue/min

The posterior spinal arteries perfuse...

the posterior 1/3 of the spinal cord (green area)

Gay-Lussac's Law

the pressure of a gas is directly proportional to the Kelvin temperature if the volume is constant

The corticospinal tract is often referred to as...

the pyramidal tract -the pyramids are formed by the corticospinal neurons as they run through the medulla

What is posterior and inferior to the axillary artery?

the radial and ulnar nerve.

spinal facet joints

the superior articular process of one vertebrae & the inferior articular process of the vertebrae directly above

When it comes to regional anesthesia/analgesia of the shoulder, arm and hand, which approach can do it all?

the supraclavicular approach to the brachial plexus is the one block that can do it all!

Why are steroids contraindicated w/ TBI

they cause hyperglycemia -> acidosis

What part of the spine is generally not affected by RA?

thoracolumbar spine

Best surgical treatment for the patient with myasthenia gravis

thymectomy in MG thymus gland produces antibodies that destroy the postjunctional nicotinic receptors at the NMJ

Aqueduct of Sylvius

transports CSF b/w 3rd and 4th ventricle

If too posterior with interscalene block, what will you see?

trapezius stimulation -need to drop the needle

Second order neurons of the dorsal column are joined by the...

trigeminal nerve

tic douloureux

trigeminal neuralgia (CN V) Excruciating pain in the face

Supraclavicular block level

trunks/divisions

Methods to reduce cerebral mass

tumor debulking hematoma evacuation

What nerve is most likely to get injured in the OR?

ulnar

T10 dermatome

umbilicus

Which of the following herbal agents reduce MAC (2) (ginko biloba, garlic, valerian, kava kava)

valerian, kava kava

The most frequent manifestation of sickle cell disease is:

vaso-occlusive crisis

CV affects of Neuraxial anesthesia

vasodilates arterial and venous, but mainly affects venous capacitance. ↓venous return, CO & BP treat w/ volume

Leading cause of morbidity and mortality after subarachnoid hemorrhage

vasospasm

What is the most significant thing to monitor postop?

ventilatory failure

Where do motor and autonomic neurons exit?

ventral nerve root

The venous blood from the basal brain structures drain...

via the inferior sagittal sinus, vein of Galen, and straight sinuses

The venous blood from the cerebral cortex and cerebellum drains...

via the superior sagittal sinus and dural sinuses

occipital lobe

visual processing

With epidural anesthesia , _____________ is the primary determinant of spread

volume

Anticoagulated pt w/ TBI

warfarin reversal: FFP, prothrombin complex concentrate, recombinant factor VIIa Anti-platement med: Platelet infusion

Monroe-Kellie Doctrine

when one content in the skull increases, another must decrease to compensate and maintain normal ICP

RA is 2-3 times more common in...

women

S/S of subarachnoid hemorrhage

worst HA of their life N/V photophobia fever When blood blocks CSF, ICP increases

T6 dermatome

xiphoid process

Is the infraclavicular block more painful than interscalene or supraclavicular?

yes

Cardiac considerations of scoliosis

↑PVR -> RV hypertrophy Mitral valve prolapse Mitral valve regurg Coarctation of the aorta

A GCS of what indicates need for ICP measurement?

≤7

What does one vial of ryanodex contain?

250mg Requires 5mL of sterile water to reconstitute

An *interscalene block* is best for procedures involving the _____________ and the ______________.

- shoulder - proximal upper extremity

The cuff should be inflated to around

250mmhg or at least 100mmhg over SBP

Spinal cord has how many paired spinal nerves?

31

Number of paired spinal nerves

31 -formed by a dorsal (posterior/sensory) and ventral (anterior/motor & autonomic)

Where do you inject LA for a *radial n.* block at the wrist? Why?

- subq injection (field block) of 10mL proximal to radial styloid - field block needed b/c several branches of radial n. at this point in wrist

What are the anatomic landmarks of an *ulnar n.* block at the wrist?

- ulnar styloid - ulnar pulse - flexor carpi ulnaris tendon

4 Types of glial cells

-Astrocytes -Oligodendrocytes -Microglia -Ependymal cells

Big picture of the Lumboscral Plexus anatomy

* commom fibular nerve is another name for common peroneal nerve

Supraclavicular complications

**Pneumo (highest of all the blocks) - cupola of the lung is just medial to the first rib Horner's syndrome Subclavian artery injection (aspirate!)

Infraclavicular complications

**Venous inj (higher than supraclav) pnemo (lower than supraclav) discomfort rarely blocks the phrenic nerve

Factors that increase the risk of cauda equina

5% lidocaine and spinal micro catheters (focus high concentrations of LA in one area)

Considerations with Marfan's

-Minimize wall stress for aortic dissection with beta blockers -Careful with PIP (d/t spontaneous pneumothorax risk) -Careful with positioning -Pregnancy increases the risk of CV complications

Describe the technique for an epidural blood patch

*Definitive tx for PDPH* - sterile technique - draw 10-20cc of venous blood - reintroduce blood into epidural space

Name the 5 terminal nerves and their origins at the level of the ankle

*Femoral n.* 1. saphenous n. *Sciatic n.* 2. deep peroneal n. 3. sup. peroneal n. 4. sural n. 5. post. tibial n.

Describe the anatomical position of the *lateral femoral cutaneous n.*

- emerges at midpoint of psoas muscle - travels laterally along anterior iliac spine - passes under lateral border of inguinal ligament

*Hydrophilic* Opioids: CSF spread

- extensive - wide band of analgesia - more rostral spread (to brain)

What are the 4 types of *non-cutting* tip spinal needles?

*Pencil Point*: 1. Whitacre (small rectangle hole on shaft) 2. Sprotte (narrow oval hole on shaft) 3. Pencan *Rounded Bevel*: 4. Greene (triangular hole near bevel)

What are the anatomic landmarks for a *median n.* at the wrist?

- flexor carpi radialis tendon - flexor palmaris longus tendon

Classic presentation of PDPH

- fronto-occipital HA - n/v - photophobia - diplopia - tinnitus Sitting = worsens Supine = relief

Describe the anatomical position of the *sciatic n.*

- 2 nerves w/in a sheath (tibial n. + peroneal n.) - exits pelvis inferior to piriformis m. via the great sacrosciatic foramen

Describe the anatomical position of the sciatic n.

- 2 nerves w/in a sheath (tibial n. + peroneal n.) - exits pelvis inferior to piriformis m. via the great sacrosciatic foramen

How do you perform a field block for the intercostobrachial nerve?

- ABDuct and externally rotate arm, begin @ detloid prominence and move inferiorly - Total vol of LA = 5mL

Describe the anatomical position of the *femoral n.*

- Biggest of the 3 nerves - forms near middle and lower 3rd of psoas muscle - courses distally in groove created by psoas major and iliac muscle - continues under inguinal ligament - lies anterior to iliopsoas muscle, lateral to to femoral a. -splits into anterior and posterior branch- gives rise to saphenous nerve near knee

What are the 4 CONS of cutting tip spinal needles (Quincke + Pitkin)?

- Higher risk of Post Dural Puncture Headache (PDPH) - Less tactile feel - Needle more easily deflected - More likely to injure cauda equina

What factors *increase* the specific gravity of CSF?

- hyperglycemia - uremia - high protein content - advanced age - cold temp *increased viscosity

Most common co-existing heart condition with scoliosis? -Other heart complication with scoliosis

-Mitral valve prolapse -Mitral regurgitation and coarctation of the aorta may also occur

Where do you inject LA for an *ulnar n.* block at the wrist?

- Inject 3-5mL medial to and below Flexor Carpi Ulnaris tendon - Confirm negative aspiration d/t proximity of ulnar artery

What are the 4 PROS of non-cutting tip spinal needles (Whitacre, Sprotte, Pencan, Greene)?

- Lower risk of PDPH - More tactile feel - Needle less likely to deflect - Less likely to injure cauda equina

Sensory innervation of the UE: VENTRAL PORTION

- Median n. - Ulnar n. -Musculocutaneos n. (lateral + medial cords)

What is the treatment for TNS?

- NSAIDs - Opioids - Trigger point injections

*Coccygeal Plexus* Primary Nerves

- Pudendal - Inferior Anal - Perineal

What is the name of the *cutting tip* spinal needle?

- Quincke - Pitkin "pitkin cut"

Sensory innervation of the UE: DORSAL PORTION

- Radial n. - Axillary n. (posterior cord)

Which surgical procedures are NOT well suited for an *axillary block*?

- Upper extremity ABOVE elbow

Which surgical procedures are best with an *axillary block*?

- Upper extremity DISTAL to elbow (forarm /hand)

Describe the anatomical position of the *obturator n.*.

- arises from medial border of psoas at level of sacroiliac joint - travels distally into pelvis minor thru obturator canal

Describe the anatomical position of the obturator n.

- arises from medial border of psoas at level of sacroiliac joint - travels distally into pelvis minor thru obturator canal

What factors DO NOT significantly affect spread of LA in the subarachnoid space? (7)

- barbotage - inc. intra-abd pressure (coughing, labor) - speed of injection - orientation of bevel - addition of vasoconstrictor - weight - gender

Treatment for PDPH (6)

- bed rest - hydration - NSAIDs - caffeine - epidural blood patch -sphenopalantine ganglion block

What are the signs and symptoms of CES?

- bowel/bladder dysfxn - sensory deficits - weakness and/or - paralysis

Describe the anatomical position of the *musculocutaneous nerve*

- contained w/in coracobrachialis muscle - coracobrachialis m. not contained in sheath surrounding axillary a. - must be blocked separately

How do neuraxial opioids reduce neurotransmission in the substantia gelatinosa?

- decreased cAMP - decreased Ca+2 conductance (pre-synaptic neuron) - increased K+ conductance (post-synaptic neuron)

Cerebral autoregulation is mediated by... (3)

-Products of local metabolism -Myogenic mechanisms -Autonomic innervation

The *psoas compartment* block targets which 3 major nerves of the lumbar plexus?

- lateral femoral cutaneous n. - femoral n. - obturator n.

List 3 descriptors of the anatomical position of the *lumbar plexus* within the *psoas compartment*

- lateral to the vertebral column - anterior to quad lumborum muscle - posterior to psoas muscle

What factors *decrease* the specific gravity of CSF?

- liver dz - jaundice - warm temp

How does an epidural hematoma present?

- lower extremity weakness - numbness - lower back pain - bowel and bladder dysfxn

*Lipophilic* Opioids: CSF spread

- minimal - narrow band of analgesia - less rostral spread

What causes transient neurologic symptoms (TNS)?

- patient positioning - stretching of sciatic n. - myofascial strain - muscle spasm *NOT likely that neurotoxicity is a cause

The *sciatic n.* provides MOTOR innervation to______________.

- posterior thigh - lower leg + foot via branches (tibial + common peroneal)

Horner's Syndrome is indicated by which 3 symptoms?

- ptosis - miosis (pupil constriction) - anhidrosis

Describe the anatomical position of the *sciatic n.* in the proximal popliteal fossa

- sciatic n. is posterior + lateral to popliteal artery + vein - sciatic n. is bordered medially by semitendinosus + semimembranosus muscles - sciatic n. bordered laterally by biceps femoris muscle

What are the signs and symptoms of TNS?

- severe back and butt pain that radiates to both legs - develops w/in 6-36 hours - persists 1 - 7 days

What is the physiological explanation of the *Bezold-Jarish* reflex?

- venous pooling in lower extremities = decreased venous return - combo effects of an unloaded ventricle, SNS stim, and epi uptake (from block) = profoundly underfilled ventricle - underfilled ventricle slows HR to increase diastolic filling time

Fentanyl Intrathecal dose Epidural dose Epidural Infusion dose

-10 - 20 mcg -50-100mcg -25-100mcg

Ligamentum Flavum -How many flava -Form the ___ margins of the epidural space -Thinnest/thickest in the lumbar region -Piercing the ligamentum flavum contributes to what when passing a needle into the epidural space

-2 flava that run the length of the spinal canal -Form the dorsolateral margins of the epidural space -Thickest in the lumbar region -Piercing the ligamentum flavum contributes to the loss of resistance when the needle enters the epidural space

Dantrolene dose for MH When should you stop giving it? What is a common SE?

-2.5mg/kg IV q5-10 minutes -Stop dantrolene when sx of hypermetabolism reside -Venous irritation common

Continuous Femoral Nerve Block Provides analgesia for ________ After a bolus, what is the rate the LA should infuse? What are the common drugs used?

-48h -8-10ml/hr -0.2% ropi or 0.25% bupi

Sufentanil Intrathecal dose: Epidural dose: Epidural Infusion dose:

-5 - 10 mcg -25 - 50 mcg -10 - 20 mcg/hr *half of fentanyl dose

Sacrum consists of how many vertebra? -Superior iliac spines coincide with __ which denotes the location of __ in adults

-5 sacral vertebrae -Superior iliac spines coincide with S2 which denotes the location of dural sac in adults (dural sac ends at S3 in neonates)

Etiology of scoliosis

-80% are idiopathic -Congenital -Myopathic (muscular dystrophy, amyotonia congenita) -Neuropathic (cerebral palsy, syringomyelia, friedreich's ataxia) -Traumatic

Microglia function

-Act as macrophages and phagocytize neuronal debris

Familial periodic paralysis

-Acute episodes of skeletal muscle weakness accompanied by changes in serum potassium -Disorder of skeletal muscle membrane, not the NMJ *2 variants of the disease hypoK and HyperK

Medical management of RA -Aim -Drugs

-Aim to reduce inflammation with antirheumatics, glucocorticoids and NSAIDs

Medical treatment of SLE -Aim -Meds

-Aims to suppress immune system and reduce inflammatory response -Corticosteroids, NSAIDs, immunosuppressants (cyclophosphamide, azathioprine, methotrexate, mycophenolate mofetil) , and antimalarials (hydroxychloroquine and quinacrine) *Cyclophosphamide inhibits plasma cholinesterase and increases duration of succs

Complications of scleroderma -Airway -Lungs -Heart -Blood vessels -Kidneys -Peripheral and cranial nerves -Eyes

-Airway: skin fibrosis limits mouth opening -Lungs: pulmonary fibrosis, pulm HTN -Heart: dysrhythmias and CHF -Blood vessels: decreased compliance, HTN -Kidneys: renal failure, renal artery stenosis -Peripheral and cranial nerves: neuropathy d/t nerve entrapment by tight connective tissue -Eyes: dry eyes predisposing to corneal abrasions

How do you preform a wake up test?

-Anesthetic agents turned off to wake patient. Patient is asked to move hands and feet. Patient then re-anesthetized -If pt is unresponsive: wait or reverse reversible agents (NMB, opioids, benzos) -If pt can move hands but not feet, the surgeon should reduce distraction of the spinal rods

When are motor evoked potentials (MEP) used? -Motor or sensory function? -Can you use NMB?

-Anterior cord -Anterior spinal artery -Monitor motor function -Do NOT use NMB

What ligaments should the needle NEVER pass through with either the midline or paramedian approach to the epidural space?

-Anterior longitudinal ligament -Posterior longitudinal ligament

Draw a diagram of the anatomy of a vertebrae

-Anterior segment -Posterior segment -Lamina -Pedicale -Body -Transverse process -Spinous process -Facet (aka superior articular process) -Vertebral foramen: contains spinal cord, nerve roots, epidural space

Circulation of 2 posterior spinal arteries

-Aorta - subclavian - vertebral - posterior spinal -Aorta - segmental - posterior radicular - posterior spinal

Classic problem in Ehlers-Danlos

-Arterial aneurysm and increased bleeding tendency d/t poor vessel integrity (NOT coagulopathy) -Common complication is pneumothorax

Patients with myotonic dystrophy are at risk for...

-Aspiration -Respiratory muscle weakness -Cardiomyopathy and dysrhythmias -Sensitivity to anesthetics *Safe to administer halogenated anesthetics, NOT at an increased risk of MH

Paget's disease definition -Cause

-Associated with excess osteoblastic and osteoclastic activity that causes abnormally thick, but weak, bone deposits -Caused by excessive parathyroid hormone or calcitonin deficiency -No vascular involvement

Most common airway complication of RA? -Why -Risks -Surgical correction

-Atlantoaxial subluxation and separation of the atlanto-odontoid articulation -D/t weakening of the transverse axial ligament -Risk of spinal cord and vertebral artery compression with quadriparesis or paralysis -Surgical correction entails odontoid decompression and posterior cervical fusion *AO instability allows odontoid to directly compress the spinal cord at the level of the foramen magnum

Systemic lupus erythematosus definition

-Autoimmune disease characterized by the proliferation of antinuclear antibodies -Targets young women (1:1000)

Rheumatoid arthritis definition and pathophysiology

-Autoimmune disease that targets the synovial joints -Widespread systemic involvement d/t infiltration of immune complexes into small and medium arteries leading to vasculitis -Cytokines (TNF and interleukin-1) play a role

What order are fibers blocked in? (motor, autonomic, sensory) *Different types of nerves have different sensitivities to LA blockade

-Autonomic fibers - blocked 1st (blocks 2-6 dermatomes higher than sensory block) -Sensory fibers - blocked 2nd (blocks 2 dermatomes higher than motor block) -Motor neurons - blocked 3rd

Considerations for Ehlers-Danlos

-Avoid regional and IM injections d/t bleeding risk *Excessive bleeding can occur with invasive line placement or trauma during airway management

Where is the axon hillock located? What does the axon do?

-Between soma and axon of a neuron -Sends signals

Why is a difficult airway a contraindication for neuraxial anesthesia?

-Block failure may require rapid conversion to GA -Depression of reticular activating system is common and may contribute to sedation. IV sedatives may lead to airway obstruction or collapse

How does neuraxial anesthesia cause bradycardia? (3)

-Blockade of the pregang. cardioaccelerator fibers at T1-T4 (this promotes a relative inc. of parasympathetic tone) (B fibers) - unloading of ventricular mechanoreceptors (Bezold-Jarisch reflex) - unloading of stretch receptors in the SA node

Epidural hematoma definition -Compresses what -Causes -Treatment

-Blood that accumulates between the dura and bone which compresses the dura and can compress the spinal cord -Causes spinal cord ischemia and permanent neurological dysfunction -Surgical decompression within 8 hours proves the best chances of recovery

Unique finding in osteogenesis imperfecta

-Blue sclera -Sclere is also susceptible to fracture

Upper extremity complications with prone position and scoliosis

-Brachial plexus injury -Ulnar nerve injury

Classic problem in osteogenesis imperfecta

-Brittle bones -Fractures may occur during NIBP inflation or following fasciculations with succinylcholine -Risk of C-spine fracture and reduced cervical ROM during airway management

4 Methods to reduce ICP (general concepts)

-CBV reduction -CSF reduction -Cerebral edema reduction -Cerebral mass reduction (tumor debulking or hematoma evacuation)

Continuous interscalene block:

-Catheter is postioned near trunks of BP between scalene muscles -Catheter inserted 3-5cm beyond tip of block needle -Following initial bolus, rate of 5ml/hr is infused

Amyotrophic Lateral Sclerosis (ALS) Definition

-Causes progressive degeneration of motor neurons in the corticospinal tract -Astrocytic gliosis replaces the affected motor neurons -Etiology is unknown

The brain can be divided into 4 areas:

-Cerebral hemispheres -Diencephalon -Brainstem -Cerebellum

Anesthetic considerations with scoliosis -Cervical scoliosis -NO2 -Thoracic correction -Blood loss -Temperature regulation

-Cervical scoliosis: may have difficult intubation -NO2 increases PVR -Thoracic correction higher than T8 may require one lung ventilation -Prepare for significant blood loss: IVs, type and cross, autologous donation, cell saver -Use active warming: forced air warmer, fluids

Contraindications to neuraxial anesthesia (11)

-Coagulopathy -Increased intracranial pressure (increased chance of brain herniation with sudden change in CSF pressure) -Sepsis (Introducing infection across BBB, worsening HoTN) -Infection at puncture site (Infection across BBB) -Hypovolemia (worsening HoTN) -Valve lesions with fixed stroke volume (AS, MS, hypertrophic cardiomyopathy) -Scoliosis/Arthritis/Spinal fusion/osteoporosis (more difficult) -Difficult airway -Full stomach (HoTN may cause nausea and vomiting) -Peripheral neuropathy -Multiple Sclerosis (epidural is safe but an intrathecal technique may exacerbate symptoms. Real world ok, NCE contraindication)

The femoral block is the most ________ lower extremity block. It does not provide_______ ______ for surgical anesthesia. Which block can it be combined with to provide a complete block?

-Common -Does not provide sufficient coverage -Sciatic block for complete LE surgical coverage

Filum terminale definition

-Continuation of the pia mater caudal to the conus medullaris. Anchors the spinal cord to the coccyx -Internal portion extends from the conus medullaris to the dural sac, external portion extends from the dural sac to the sacrum

Treatment of MS -What needs to be avoided

-Corticosteroids, interferon, and azathioprine -S/Sx can be exacerbated by stress and increased body temperature (as small as 1*C) -Succinylcholine can cause life-threatening hyperkalemia

What are the boundaries of the epidural space? -Cranial border -Caudal border -Anterior border -Lateral border -Posterior borders

-Cranial border: foramen magnum -Caudal border: sacrococcygeal ligament -Anterior border : posterior longitudinal ligament -Lateral border: vertebral pedicles -Posterior borders: ligamentum flavum and vertebral lamina *epidural space is shallow anteriorly, but deeper posteriorly, esp. in lumbar region

Anesthetic considerations for SLE -Cricoarytenoid arthritis -Antiphospholipid antibodies -Cyclophosphamide

-Cricoarytenoid arthritis increases risk of postextubation laryngeal swelling and airway obstruction (treat with steroids and consider smaller ETT -Antiphospholipid antibodies may develop (prone to hypercoagulability and thrombus even with prolonged aPTT - stroke, DVT, PE) -Cyclophosphamide inhibits plasma cholinesterase and increases duration of succs -Pregnancy, stress, infection, and surgery can exacerbate s/sx

Airway complications of SLE

-Cricoarytenoiditis (hoarseness, stridor, airway obstruction) -Recurrent laryngeal nerve palsy

Cerebrospinal fluid functions (3)

-Cushions the brain -Provides buoyancy -Delivers optimal conditions for neurologic function

Anesthetic considerations with cricoarytenoid arthritis

-Decreased glottic diameter may increased the difficulty of passing an ETT -Use smaller ETT to minimize laryngeal trauma -Patient at risk of postextubation airway obstruction

Cardiac Considerations w/ DMD patients

-Degeneration of cardiac muscle: ↓contractility, papillary muscle dysfxn, Mitral regurg, cardiomyopathy, CHF -s/s of cardiomyopathy: tachycardia, JVD, S3/S4 gallop, displacement of point of maximal impulse -gold standard for evaluation is echo, can also do cardiac MRI

Multiple Sclerosis Definition -Symptoms -Cranial nerve involvement

-Demyelinating disease of the CNS -Patients experience sensory and motor deficiencies as well as autonomic instability -Cranial nerve involvement causes bulbar muscle dysfunction (aspiration risk)

Describe the site of action for epidural anesthesia -1st diffuse through __ -LAs also leak through __ to enter __

-Epidural space -LAs must 1st diffuse through dural cuff before they can block the nerve roots -LAs also leak through the intervertebral foramen to enter the paravertebral area - here, LAs can cause multiple paravertebral blocks

Epidural space communicates with the paravertebral space by way of ____ foramina -Epidural fat is a sink for lipophilic drugs (__>__>__)

-Epidural space communicates with the paravertebral space by way of the intervertebral foramina -Epidural space contains nerve roots, fat pads, and blood vessels. Epidural fat acts as a sink for lipophilic drugs, reducing bioavailability (bupivacaine> lidocaine and fentanyl> morphine) (Bupivacaine is more lipophilic and has decreased bioavailability; thus, you can give an increased dose)

Scleroderma Definition

-Excessive fibrosis in the skin and organs, particular in the microvasculature

How do spinal nerves exit the vertebral column?

-Exit via the intervertebral foramina

Components of cryoprecipitate

-Factor VI -Fibrinogen -Factor XIII -Fibronectin -Von-Willebrand Factor -80 uL of Factor VII/unit >150 mg/dL fibrinogen

Herniation of the temporal uncus results in what sign?

-Fixed and dilated pupil d/t compression and ischemia of the oculomotor nerve (CN III) -Oculomotor nerve originates from the midbrain and crosses near the tentorium

S/sx of anterior spinal artery syndrome

-Flaccid paralysis of lower extremities -Bowel and bladder dysfunction -Loss of temperature and pain sensation -*Preserved touch and proprioception (because the anterior circulation does not perfuse the dorsal column)

What are the 4 lobes of each cerebral hemisphere -What do they contain?

-Frontal - contains motor cortex -Parietal - contains somatic sensory cortex -Occipital - contains vision cortex -Temporal - contains auditory cortex and speech centers

Drug-induced lupus -Length of exacerbation -Symptoms

-Generally persists for several weeks to months -Mild symptoms of arthralgia, anemia, leukopenia, and fever

Positioning ways to increase venous outflow?

-Head elevation >30 degrees (head down increases CBV and ICP_ -Neck neutral (neck flexion or extension can compress the jugular veins, reduce venous outflow, increase CBV and increase ICP)

What are the respiratory effects of neuraxial anesthesia? -Healthy patients -Accessory muscles (intercostals, abd muscles)

-Healthy patients: negligible effects -Accessory muscle function is reduced which decreases pulmonary reserve (very important with COPD) - impaired intercostals (insp+exp) - impaired abd muscles (cough+clr)

Brain herniation tends to occur at 4 different locations:

-Herniation of the cingulate gyrus over the falx -Herniation of contents over the tentorium cerebelli (transtentorial herniation) -Herniation of the cerebellar tonsils through the foramen magnum -Herniation of contents through a site of surgery or trauma

Cricoarytenoid arthritis presents with...

-Hoarseness, stridor, dyspnea, edema/erythema of the vocal cords -May result in airway obstruction

How can you decrease cerebral blood flow? (4 broad)

-Hyperventilation (PaCO2 30-35mmHg constricts cerebral vessels→↑ cerebral vascular resistance →↓CBF →↓ICP ) -Avoid Hypoxemia (PaO2 <50-60mmHg increases CBF and ICP) -Drugs (Avoid cerebral vasodilators like nitroglycerine, nitroprusside; administer drugs to reduce CMRO2 (considered cerebral vasoconstrictors) like thiopental, propofol) -Hemodynamics (avoid extreme HTN which would cause cerebral edema)

How to measure the Cobb angle

-Identify the 2 most displaced vertebrae (top and bottom) -Line drawn parallel to each -Perpendicular line drawn from each of these lines -Angle where they intersect is the Cobb angle

How can mannitol increase cerebral edema? ICP?

-If BBB disrupted, mannitol enters brain and increases cerebral edema -Mannitol transiently increases blood volume which can increase ICP and stress a failing heart

Patho of neurogenic shock Hint: HR, inotropy, CO/BP, body temp

-Impairment of cardioaccelerator fibers (T1-T4) = bradycardia and decreased inotropy d/t unopposed cardiac vagal tone -Decreased SNS tone = vasodilation, venous pooling and decreased CO/BP -Sympathetic impairment from hypothalamus to blood vessels which inhibits vasoconstriction or shivering = hypothermia *Hypothermia is the result of the inability of cutaneous vasculature to vasoconstrict which redistributes blood flow to the periphery causing heat to escape

MOA of disease-modifying antirheumatic drugs

-Improve symptoms by inhibiting tumor necrosis factor (TNF), interleukin-1 and -6, and inhibit T cells and B lymphocytes *These drugs suppress the immune system and increase risk of infection and cancer

Why does autonomic hyperreflexia occur?

-In chronic phase of SCI, sympathetic reflexes below level of injury return; however, they return in a hyperactive state because inhibitory influences from above the level of injury are severed

Causes of increased CSF

-Increased CSF production by choroid plexus -Reduced CSF removal by arachnoid villi -Obstruction of reabsorption (bleed, infection, tumor) -Passage of fluid across the BBB

Abdomen complications with prone position and scoliosis

-Increased abdominal pressure --transmitted to veins that drain spine - > back bleeding (no valves) --Reduced pulmonary compliance (Jackson frame is better than Wilson frame)

Increased intrathoracic pressure increases/decreases venous outflow? -How an you decrease intrathoracic pressure?

-Increased intrathoracic pressure decreases venous outflow -Avoid PEEP, bucking, coughing, straining to decrease intrathoracic pressure -Increases intrathoracic pressure, and reduces venous drainage from brain

A subset of neurons in the corticospinal tract exert excitatory/inhibitory influence on lower motor neurons. -Significance?

-Inhibitory influence over lower motor neurons -Prevents lower motor neurons from firing too frequently

Eye complications with prone position and scoliosis

-Ischemic optic neuropathy d/t hypoperfusion and/or increased venous pressure -Corneal abrasion

Conditions that impair venous drainage

-Jugular compression with improper head positioning -Increased intrathoracic pressure secondary to coughing or PEEP -Vena cava thrombosis -Vena cava syndrome - blocked superior vena cava

Respiratory Considerations w/ DMD patients

-Kyphoscoliosis (restrictive lung disease) -> ↓pulmonary reserve -> ↑secretions & risk for pneumonia -Respiratory muscle weakness

Pulmonary considerations of osteogenesis imperfecta

-Kyphoscoliosis and pectus excavatum reduce chest wall compliance and vital capacity, leading to VQ mismatch and hypoxemia

The corticospinal tract is made up of 2 tracts -What do they innervate?

-Lateral corticospinal tract: Limb fibers -Ventral corticospinal tract: Axial (head, neck and trunk) fibers

Technique for caudal anesthesia:

-Lateral(simms postions)/prone(frog leg and use a roll to support iliac crests) -use superior iliac crests for landmarks to find trianglular sacrum -Bevel up thru sacral hiatus aim cephalad -Needle tip beyond S2-S3 increases risk for dural puncture -Aspirate for blood/csf- do not use AIR for loss of resistance (may cause air embolism)

Anesthetic mgmt of parkinsons

-Levodopa half life 6-12 hours. Should be taken morning of surgery. Must be administered via OG for longer procedures -Antidopaminergic drugs are contraindicated (metaclopramide, haloperidol, droperidol, promethazine) -Anticholinergics can be used to treat exacerbations -No contraindication to NMB's -Do not use alfentanil or Ketamine

What drugs can be given to reduce cerebral edema? How? Hint: Diuretics and Corticosteroids

-Loop Diuretics: induce diuresis and decrease CSF production -Osmotic diuretics (Mannitol 0.25-1.0 g/kg): increases serum osmolarity and pulls water across BBB -High tonicity fluid (3% NaCL): pulls water across BBB -Dexamethasone/Methylprednisolone: reduce cerebral edema caused by mass lesions (also used with spinal cord injuries)

Effect on CBF -Metabolic acidosis -Respiratory acidosis -Respiratory alkalosis

-Metabolic acidosis : No effect (hydrogen does not pass through the BBB) -Respiratory acidosis: increases CBF -Respiratory alkalosis: decreased CBF

Examples of disease-modifying antirheumatic drugs and common side effects -Individual side effects of each med

-Methotrexate, cyclosporine, and etanercept -Methotrexate causes liver dysfunction and suppresses the bone marrow -Cyclosporine prolongs the duration of succinylcholine

S/Sx of RA

-Morning stiffness -Joints are painful, swollen, and warm -Weakness, fatigue, anorexia -Lymph node enlargement in cervical, axillary, and epitrochlear (upper arm) regions

Hallmark of RA

-Morning stiffness that generally improves with activity -Joints are painful, swollen, and warm

how to approach the interscalene block

-Most proximal approach to the brachial plexus -A paravertebral approach at the cervical roots in the neck -Relatively easy place to enter the brachial plexus sheath and elicit a parasthesia shallow block.

A-Alpha Fibers -Myelination -Function -Diameter -Conduction velocity -Block onset

-Myelination: heavy myelination -Function: skeletal muscle (motor), proprioception -Diameter: 12-20 -Conduction velocity: +++++ -Block onset: 4th Alpha male *heavy* liftin' Bulky *muscles* and *proprioception* *12-20* reps with a *5 star speed* Still *4th* place on my Tinder rotation

Treatment for neurogenic shock

-NE to restore SVR and inotropy -Volume expansion - over resuscitation may lead to myocardia dysfunction and pulmonary edema --Use an A line to determine the adequacy of both NE and volume expansion

Secondary s/sx of autonomic hyperreflexia

-Nasal stuffiness d/t vasodilation above the level of injury -Headache and blurred vision d/t hypertension -Stroke, seizure, LV failure, dysrhythmias, pulmonary edema, MI from malignant hypertension

How accurate is nerve stimulation?

-Nerve stimulator settings have no consistent relationship to proximity to the nerve and can be misleading. -Conditions such as the neuropathy associated with diabetes can render the nerve stimulator almost worthless. -Poor return electrode placement and inconsistent contact in the active electrode can further muddy the issues.

How does neuraxial anesthesia affect the neuroendocrine response to stress? -Reduces circulating levels of...

-Neuraxial anesthesia diminishes surgical stress response by inhibiting afferent traffic originating from surgical site -This reduces circulating levels of: catecholamines, renin, angiotensin, glucose, thyroid stimulating hormone, growth hormone

Differential blockade Epidural Anesthesia -Autonomic differential blockade -Sensory block

-No autonomic differential blockade with epidural anesthesia -Sensory block is 2-4 dermatomes higher than motor block *Not likely to drop BP

Paralytic choice for patients with ALS

-No succinylcholine: can cause lethal hyperkalemia d/t lower motor neuron proliferation of postjunctional nicotinic receptors -Increased sensitivity to nondepolarizing NMB

Anesthetic considerations for ALS

-No support of any particular anesthetic technique -Increased risk of aspiration (bulbar muscle dysfunction) -Chest weakness reduces vital capacity and maximal minute ventilation -May need postop mechanical ventilation

Can you use succinylcholine in patients with Gullian-Barre? Is GB sensitive to non depolarizers?

-No- avoid succs- risk of hyperK+ from proliferation of extrajunctional Ach receptors -Yes increased sensitivity to NDNMB

Block onset order -Block regression order

-Onset: B, C, A delta and gamma, A alpha and beta (pre-ganglionic sympathetic, temp, pin prick (fast pain), touch. motor) -Regression is in opposite order of onset

Most common problems with Paget's disease

-Pain and fractures -Peripheral nerve entrapment may occur

Why is peripheral neuropathy a contraindication for neuraxial anesthesia?

-Patients more susceptible to injury, slower to recover *More of a legal thing than scientific thing

Cranial nerves are part of the central or peripheral nervous system? -Which one is the exception?

-Peripheral nervous system -Optic Nerve (II) is part of the central nervous system and is surrounded by dura

Median Nerve: SENSORY test MOTOR test

-Pinch index finger -Thumb opposition

Musculocutaneous Nerve: SENSORY test MOTOR test

-Pinch lateral asepct of forearm -Elbow flexion (biceps contraction)

Axillary Nerve: SENSORY test MOTOR test

-Pinch lateral aspect of shoulder -Arm abduction (deltoid contraction)

Ulnar Nerve SENSORY test MOTOR test

-Pinch pinky finger -Pinky finger ABDuction

Radial Nerve: SENSORY test MOTOR test

-Pinch web space between thumb and index finger -Elbow extension (triceps contraction) Wrist + finger extension Radial REACTS to thumb (sensory) Medial Movement of thumb (motor)

Neuraxial Anesthesia Contraindications: Coagulopathy -Platelet count -PT, aPTT, bleeding time -Why?

-Platelet count < 100,000 -Pt, aPTT, and/or bleeding time 2x normal value -risk of spinal or epidural hematoma

Most common problems of SLE

-Polyarthritis and dermatitis -Arthritis can affect any joint, but generally does not involve the spine

When are somatosensory evoked potentials (SSEP) used? -Motor or sensory function? -Can you use NMB?

-Posterior cord (dorsal column pathway) -Posterior spinal arteries -Sensory function -SSEPs do NOT monitor motor function -NMB do not interfere with SSEP monitoring

Lower extremity complications with prone position and scoliosis

-Pressure on iliac crest -> lateral femoral cutaneous nerve injury -Pressure latera to fibula -> peroneal nerve injury -Hip flexion -> femoral vein occlusion -> DVT

What produces CSF and where is it located?

-Produced by ependymal cells of choroid plexus. -Choroid plexus is located in all 4 cerebral ventricles

Myotonic dystrophy -Definition -Physiology

-Prolonged contracture after a voluntary contraction -Result of dysfunctional calcium sequestration by the SR -Contractions can be so severe they interfere with ventilation and intubation

RA vs osteoarthristis

-RA: affects proximal interphalangeal and metacarpophalangeal joints in the hands and feet with systemic involvement -Osteoarthritis: affects weight bearing joints and no systemic involvement

Increased pulmonary vascular resistance with scoliosis causes what? -EKG

-RV hypertrophy -EKG: RV strain and RA enlargement

Astrocytes function

-Regulation of metabolic environment -Repair neuron after neuronal injury

Thalamus functions

-Relay station that directs information to various cortical structures and regulates consciousness and alertness (the reticular activating system ascending projects to the thalamus)

HTN best treated with... (3) -What type of med should you avoid?

-Removal of stimulus -Deepening anesthetic -Rapid acting vasodilator (sodium nitroprusside) -administration of a positive chronotrope with vasoconstrictive properties will worsen HTN

Pulmonary complications of SLE

-Restrictive ventilatory defect -Pulmonary HTN -Interstitial lung disease with impaired diffusing capacity -Pleural effusion -Recurrent pulmonary emboli

Early respiratory complications with scoliosis

-Restrictive ventilatory defect: decreased FEV1 and FRC but normal ratio -Decreased VC, TLC, RV, FRC, and chest wall compliance *Scoliosis alters thoracic geometry which compresses the lungs and creates a restrictive ventilatory defect. One side of the thorax becomes smaller.

Most common offenders of exacerbation of SLE

-Result from stress or drug exposure PISSED CHIMP Pregnancy, Infection, Surgery, Stress, Enalapril, D-penicillamine Captopril, Hydralazine, Isoniazid, Methyldopa, Procainamide

Laboratory findings in RA

-Rheumatoid factor (anti-immunoglobulin antibody) increased in 90% of patients with RA -C-reactive protein is increased -Erythrocyte sedimentation rate is increased

Where are ependymal cells located?

-Roof of the 3rd and 4th ventricles and spinal canal *Involved in CSF production

What does the blood brain barrier separate? What restricts passage of large molecules and ions within the BBB?

-Separates CSF from plasma -Tight junctions restrict passage of large molecules and ions (does not have carrier proteins)

EKG changes in Duchenne

-Sinus tach and short PR interval -Increased R amplitude in lead 1 -->scarring of posterobasal (back/bottom) aspect of LV) -Deep Q waves in limb leads

List all 13 structures and spaces between the skin and the spinal cord as they would be encountered during a subarachnoid block

-Skin -SubQ -Muscle -Supraspinous ligament -Interspinous ligament -Ligamentum flavum -(EPIDURAL SPACE) -Dura mater: tough fibrous protective shield that protects spinal cord, begins at foramen magnum and ends at dural sac -(SUBDURAL SPACE) -Arachnoid mater: thin connective tissue layer -(SUBARACHNOID SPACE - contains CSF, nerve roots, rootlets and spinal cord; target for spinal) -Pia mater: external covering of spinal cord, should NEVER be punctured during spinal anesthesia -Spinal cord DAPS: Dura, arachnoid, pia, spinal cord

What are watershed areas in the spine? What are they vulnerable to?

-Some regions of the cord only have a single blood supply -Vulnerable to ischemia * important to know the spinal cord is perfused in segments, not the entire length of the cord

Telangiectasia definition -Significance

-Spider veins -Increase the risk of mucosal bleeding, particularly during nasal intubation

Common events that cause autonomic hyperreflexia

-Stimulation of hollow organs (bladder, bowel, uterus) -Bladder catheterization -Surgery, especially cysto or colonoscopy -Bowel movement -Cutaneous stimulation -Childbirth

Describe the site of action for spinal anesthesia -Primary site of LA action

-Subarachnoid space -Primary site of LA action = myelinated preganglionic fibers of the spinal nerve roots LAs also inhibit neural transmission in the superficial layers of the spinal cord

3 things that increase the risk of contractors with myotonic dystrophy

-Succinylcholine (use nondepolarizer) -NMB reversal with anticholinesterases (use sugammadex instead) -Hypothermia (shivering -> sustained contractions)

Answer

-Supraspinous ligament: runs most of the length of the spine and joins the tips of the spinous processes -Interspinous ligament: travels adjacent to an joins the spinous processes -Ligamentum flavum -Posterior longitudinal ligament: travels along the posterior surface of the vertebral bodies -Anterior longitudinal ligament: attaches to the anterior surface of the vertebral bodies and extends the entire length of the spine. Also attaches to the annulus fibrosis of the intervertebral discs

SCI with neurogenic shock definition -symptoms

-Sympathectomy below the level of the injury -Hypotension, bradycardia, and hypothermia (Extremities will be warm and pink d/t vasodilation)

Where do you place a catheter for a ___ surgery -Thoracic -Upper abdominal -Middle abdominal -Lower abdominal -Lower extremity

-T4-8: Thoracic -T6-8: Upper abdominal -T7-10: Middle abdominal -T8-T11: Lower abdominal -L1-4: Lower extremity

Rheumatoid arthritis impacts the airway in 3 places:

-Temperomandibular joint (synovitis of TMJ can limit mouth opening) -Cricoarytenoid joints (decreased diameter of glottic opening) -Cervical spine (atlanto-occipital subluxation with flexion, limited extension)

What does chronic HTN do to autoregulation?

-Textbook: shifts the curve to the right (more tolerant of HTN, less tolerant of HoTN) -Reality: plateau of curve narrows and CBF is more dependent on CPP (high patient to patient variability)

Risks of wake up test

-Tracheal extubation -Removal of intravenous or arterial lines -Air embolism -Awareness -Pain -Damage to surgical instrumentation

CREST syndrome definition -S/Sx

-Type of scleroderma -Calcinosis, Raynaud's, Esophageal hypomotility, Sclerodactyly, Telangiectasia

Needles used in peripheral nerve blocks?

-Typical 22 g insulated block needles can be used. -Alternatively, 18 g Touhy needles sometimes are used, because are easier visualized, or for catheter placement.

Airway complications with prone position and scoliosis

-Upper airway edema - consider leak test -ETT kink or inadvertent extubation

What is inverse steal or the Robinhood effect? -Draw backs -Best practice

-Using hyperventilation to constrict cerebral vessels and redistribute flow to ischemic areas -Not shown to have a clinical benefit, can shift oxyhemoglobin curve to left, and reduce CBF -Maintain normocapnia or mild hypocapnia 30-35 mmHg

Cerebrospinal fluid locations (3)

-Ventricles (left lateral, right lateral, third, and fourth) -Cisterns around the brain -Subarachnoid space in brain and spinal cord

What are the anatomical boarders of the intervertebral foamina?

-Vertebral body and intervertebral disc form anterior boarder -Facet joints form posterior boarder

What occurs when CPP is greater than 150?

-Vessels are maximally constricted (also with PaCO2 of 25mmhg) -CBF becomes pressure dependent on MAP -Risk of cerebral edema and hemorrhage

What occurs when CPP is less than 50?

-Vessels are maximally dilated (also with PaCO2 80-100) -CBF becomes pressure dependent on MAP -Risk of cerebral hypoperfusion and ischemia

What is a wake up test and why is it used?

-Wake up test assesses neurologic integrity during spine surgery to avoid neurologic injury (paraplegia) -Abandoned in favor of SSEP/MEP monitoring but can still be used if these monitors fail

Cerebral Steal Phenomena

-When cerebral vasodilation (hypercapnia, hypoventilation, vasodilators) causes blood to go to healthy tissue and steal flow from ischemic areas -Healthy brain tissue has tone and diameter is based on PaCO2 -Ischemic or atherosclerotic tissue is maximally dilated

Cervical and thoracic spinous processes angle in a ___ direction -More ___ approach with a needle

-caudal direction -cephalad needle approach

Deliberate HoTN to maintain MAP 60mmHg increases risk of ___ and ___ -What should you monitor?

-cerebral hypoperfusion and ischemic optic neuropathy -Monitor end organ perfusion with serial ABG (metabolic acidosis) and urine output

Second order neuron (Dorsal)

-crosses to contralateral side in the medulla, then ascends to the thalamus via the medial lemniscus -joined by the trigeminal nerve which provides sensation to the head -synapses with the 3rd order neuron in the thalamus - ventrobasal complex

Cerebral vasospasm

-delayed contraction of cerebral arteries -can lead to cerebral infarction -can be caused with free hgb in contact with outside of cerebral arteries (ie. blood where its not supposed to be) -most common 4-9 days following SAH

Terminal end of subarachnoid space is called__ Coincides with __ in adults and __ in infants

-dural sac -S2 adults -S3 infants

The diagnosis of AO subluxation is made when the distance between the anterior arch of the atlas and the odontoid process is... -How is this best assessed?

-greater than 3mm -Best assessed with a lateral x-ray of the cervical spine

Pruiritis

-more common in obstetric patients -caused by opioid receptors in the trigeminal nucleus (NOT mast cell degranulation) -treat w/ naloxone (benadryl will not treat this, but the sedative effect may be helpful)

Lumbar spinous process projects in a ___ direction

-posterior direction -Epidurals and intrathecal spaces easier to access

Vertebra are separated by intervertebral discs that act as ___. -Disc degeneration

-shock absorbers -Disc degeneration reduces the size of intervertebral foramina and can cause nerve compression

Upper extremity nerve blocks:

1)Brachial plexus: -Interscalene, Supraclavicular, -Infraclavicular, Axillary 2)Individual nerve blocks: -Usually to supplement brachial plexus block 3)IV regional block (bier block) 4)Other Misc. blocks 5)N.A.V.E.L.- nerve (most lateral), artery, vein, empty space, lymphatics (most medial

Rank the speed of LA uptake after injection into the following sites: (1 fastest, 4 slowest) Intrapleural, caudal, brachial plexus, intercostal

1)Intrapleural 2)Intercostal 3)Caudal 4)Brachial plexus

Technique for interscalene block

1)Standard monitors 2)Crash Cart 3)Pt. supine head to contra lateral side 4)Sterile prep/drape 5)Localize skin @ level of cricoid cartilage 6)22g. 1 ½ in. needle inserted *45-70 degree angle* perpendicular and advanced in a caudal direction. 7)Very shallow Block , May feel a pop. Once parasthesia is obtained, the needle is stabilized and after negative aspiration for blood, 20 to 40 cc's of the local anesthetic solution is injected slowly and carefully.

CSF pressure

5-15 mmHg

What 2 factors increase the risk of CES?

1. 5% Lidocaine 2. Micro catheters (focus LA on a small area of the SC, exposing region to high conc. of LA)

The risk of MH is NOT increased with what syndromes?

1. Becker muscular dystrophy 2. Neuroleptic malignant syndrome 3. Myotonia congenita 4. Myotonic Dystrophy *may see this on the exam

What are the 5 determinants of blood flow?

1. Cerebral metabolic rate for oxygen 2. Cerebral perfusion pressure 3. Venous Pressure 4. PaCO2 5. PaO2

MH treatment acute phase

1. D/C triggering agent 2. Call for help, tell surgeon to end procedure 3. Hyperventilate pt w/ 100% O2, 10L/min (don't waste time changing soda lime) -Facilitates CO2 elimination -↑ O2 delivery -drives K+ into cells 4. Administer Dantrolene 5. Cool pt 6. Correct lactic acidosis (bicarb) 7. Treat hyperkalemia 8. Class I antiarrhythmics 9. Maintain UOP > 2ml/kg/h (mannitol, lasix, fluid) 10. Monitor coag panels for DIC (Late sign)

Steps of treating an MH episode

1. D/c triggering agent and call for help and tell surgeon to stop 2. Hyperventilate with 100% O2 at 10L/min (Drives K+ into cells, CO2 elimination, O2 delivery) 3. Administer Dantrolene 4. Cool patient until temperature drops below 38 5. Correct lactic acidosis 6. Treat hyperkalemia 7. Protect against dysrhythmias 8. Maintain UOP >2ml/kg/hr 9. Check coag panals- DIC is late complication and signals impending death

Bier Block: 20 - 40 min since LA injection. Can you deflate cuff?

1. Deflate 2. Immediately reinflate 3. Deflate again at 1 minute

Post spinal Bacterial meningitis: What are the 2 ways infection can reach the CSF? What is the most common culprit?

1. Failure of aseptic technique 2.Bacteria in pt's blood at time of SAB Streptococcus viridans- most commonly found in the mouth- wear a mask. Also on hands and arms

Relative contraindications d/t HoTN caused by sympthectomy

1. Fixed valve lesions = severe AS, MS, hypertrophic cardiomyopathy 2. Full stomach can lead to N/V d/t HoTN

How do you prepare for patient at risk for MH?

1. Flush anesthesia machine with hiflo O2- 20-100min 2. Remove and replace CO2 absorbent, circuit, bag 3. physically remove vaporizers from the machine - if pt doesnt present with s/sx of MH w/in 1st hr- very unlikely to occur -pt needs to be monitored in PACU for 1-4h before dc home

What are the 2 reasons why an epidural blood patch works?

1. Increases CSF pressure by compressing epidural and subarachnoid spaces 2. Acts as a plug to prevent further leaks

Conditions w/ a link to MH

1. King Denborough syndrome 2. Central core disease 3. Multiminicore disease possible link w/ hypokalemic periodic paraylysis

What 4 factors increase the risk for TNS?

1. Lidocaine 2. Lithotomy 3. Ambulatory surgery 4. Knee arthroscopy

The *lateral femoral cutaneous n.* MOTOR innervation: SENSORY innervation:

1. None 2. Lateral thigh

Order for bier block tourniquet inflation

1. PIV in operative arm 2. elevate arm for 2 minutes 3. wrap w/ esmarch 4. Inflate distal cuff 5. Inflate proximal cuff 6. Deflate distal cuff 7. Remove esmarch 8. Inject LA

What are the 5 RELATIVE contraindications to caudal anesthesia?

1. Pilonidal cyst 2. Abnormal superficial landmarks 3. Hydrocephalus 4. Intracranial tumor 5. Progressive degenerative neuropathy

Bier block procedure steps:

1. Place double cuff tourniquet on (not inflated) 2.Place 22g PIV in hand of operative site 3.elevate arm for 1-2min to allow passive exsanguination 4. tightly wrap esmarch band around arm to further exsanguinate until reach distal cuff 5. Inflate distal cuff first (helps exsanguinate further 6. inflate proximal cuff (deflate distal if you want LA to anesthetize under distal so it can be switched if torniquet pain starts happening) 7. remove esmarch 8. inject LA (usually 40-50ml 0.5% lido) 9. remove 22g PIV for surgery if it is in the surgical field (can be left in if redosing is anticipated)

What 2 features of the Tuohy needle help prevent dural puncture?

1. Pronounced curvature (30 deg) 2. Blunt tip

The big 4 side effect of neuraxial opioids

1. Pruitis 2. Respiratory depression 3. Urinary retention 4. N/V

1. Opioid in intrathecal space easily diffuses into ______ 2.opioid in epidural space diffuses into____

1. spinal cord 2. epidural tissue-->dural cuff--> CSF--->spinal cord (some also diffuses into the bloodstream so need a higher dose to reach the subarachnoid space)

Characteristics of lipophilic opioids

1. stays in CSF for a shorter period of time 2. minimal rostral spread -> narrower band of analgesia 3. Site of action: Substantia gelatinosa Rexed Lamina II & III & systemic 4. Onset is fast (5-10min) 5. Duration is shorter (2-4h) 6. more systemic absorption 7. Early (<6h) respiratory effects only 8. Low incidence of N/V & Pruritis

Characteristics of hydophilic opioids

1. stays in CSF longer 2. More extensive spread -> wide band of analgesia -> more rostral spread (toward brain) 3. Site of action: Substantia gelatinosa Rexed Lamina II & III 4. Onset is delayed (30-60min) 5. Duration is longer (6-24h) 6. Less systemic absorption 7. Early (<6h) and Late (>6h) respiratory effects 8. High incidence of N/V & Pruritis

Specific gravity of CSF

1.002 - 1.009

What is the specific gravity of CSF?

1.002 - 1.009

Specific gravity of CSF

1.002-1.009

Normal ICP

5-15 mmHg gold standard monitor is an intraventricular catheter

Most common culprits of Guillain-Barre: (3) Other causes:(3)

1.Campylobacter jejuni 2. Epstein-Barr (mono) 3. cytomegalovirus (CMV) Other: vaccinations, surgery, lymphomatous disease

Dantrolene MOA

1.Halts Ca release from the RyR1 receptor 2.Prevents Ca entry into the myocyte, reducing the stimulus for calcium-induced calcium release

The *posterior femoral cutaneous n.* MOTOR innervation: SENSORY innervation:

1.None 2. Posterior thigh

Why is a caudal block more for pediatrics?

1.Sacral anatomy is hard to ID in adults 2.Lumbar approach to epidural space is easier and equally effective in adolescence and adults

Pruritus caused by opioids: 1.Most common ___ ___ of neuraxial opioids, which patient population is it most common with? 2. what causes it? 3. How do you treat it?

1.Side effect; Obstetric patients 2. Caused by opioid stimulation of opioid receptors in trigeminal nucleus, NOT mast cell degranulation (non histamine releasing opioids can cause it- fent/sufenta) 3. opioid antagonist naloxone (benadryl doesnt fix it)

What other complications are associated with supraclavicular block? (2)

1.Stellate ganglion/horners syndrome- LA can spread proximal towards sympathetic chain on anterior vertebral body 2. LA injection into the subclavian artery

The anterolateral system transmits sensory info ___ to ___ as fast as the dorsal column (medial leminiscal)

1/2- 1/3 as fast central will be faster than lateral

Meperidine Intrathecal dose: Epidural dose: Epidural infusion dose:

10 mg 25-50mg 10-60mg/hr *Similar to sufentanil

Exception to baricity rule

10% procaine in water is hyperbaric b/c of the number of molecules in a 10% solution

Therapeutic level of phenytoin

10-20mcg/mL

How much blood is withdrawn for an epidural blood patch

10-20ml When the patient senses pressure in her legs, buttocks or back the injection is complete

What is the average amount of irrigation that is systemically absorbed during TURP?

10-30mL/min Blood loss = 2-5mL/min

Cobb angle associated with significantly impaired gas exchange and high risk for postop pulmonary complications

100 degrees

Convert 38.3C to farenheight

100.9 F = (C x 1.8) + 32

CSF pressure

5-15mmHg

After Bier block, case is completed in 10 min after injection of LA. What is the additional time you must wait before you can safely deflate the tourniquet?

10min TQ must be inflated for a minimum of 20mins after youve injected the LA

Normal ICP

5-15mmHg

During an aneurysm repair, SBP should be between....

120-150mmHg

Percentage of cardiac output going to global cerebral blood flow

15%

According to SCIP, vancomycin must be started within ___min of surgical incision

120min. all abx must be started within 1hr, vanco is the only exception

percent of cardiac output that goes to the brain

15%

To minimize the risk of intracranial hemorrhage during DBS, SBP should not exceed...

140mmHg

What is the angle of a Hustead needle?

15 degrees

CSF volume

150mL

At what level of CBF is there complete cortical suppression?

15mL/100g/min

Core temp may rise within ____min of exposure, but profound hyperthermia is a ______ sign

15min ; late sign

Hughstead epidural needle

15°

At what temperature does EEG suppression occur?

18-20°C

Where do motor neurons travel? (General both limb and axial muscles)

1: Exit the pre central gyrus in the frontal lobe of the cerebral cortex (upper motor neuron) 2: Pass through the internal capsule 3: Travel inferiorly through the pyramids of the medulla 4: Synapse in the ventral horn of the spinal cord to limb or axial muscles (lower motor neuron)

Autonomic Hyperreflexia pathway -Stimulation below level of spinal cord injury...

1: stimulation below level of spinal cord injury 2: activation of sympathetic nerves 3: Vasoconstriction below level of injury 4: HTN 5: Baroreceptor reflex stimulation in carotid sinus 6: Bradycardia and vasodilation above the level of injury *Sympathetic nerves below the level of injury do NOT receive inhibitory signals from brain and do NOT vasodilate when baroreceptor reflex is activated

Dantrolene infusion dose on ICU

1mg/kg q 6h or 0.1-0.3mg/kg/h for 48-72h

Dantrolene dose in ICU following MH episode

1mg/kg q6hr or 0.1-0.3mg/kg/hr for 48-72 hours

What is the minimum amount of LA injected into the vertebral artery that can cause seizures?

1ml

C6 innervation

1st digit, thumb

Match each neuron in the spinothalamic tract to the location where its cell body resides? 1st order neuron- 2nd order neuron- 3rd order neuron-

1st order neuron- dorsal root ganglion 2nd order neuron- dorsal horn 3rd order neuron- thalamus

Order of block

1st: Autonomic nerves (first) 2nd: Sensory fibers 3rd: Motor fibers (last) The highest level will be autonomic nerves (2-6 dermatomes higher than sensory) sensory will be blocked at a higher level than motor fibers (2 dermatomes higher than motor)

Spinal cord circulation consists of...

2 posterior spinal arteries 1 anterior spinal artery 6-8 radicular arteries

Which local anesthetic reduces the efficacy of epidural opioids?

2-chloroprocaine

Max dose of Ropivicaine for peripheral nerve block?

2.5 mg/kg or 250 mg

Potassium in CSF compared to plasma

2.8 in CSF vs. 4.5 in plasma

Minimum amount of time the tourniquet needs to stay inflated w/ a bier block?

20 minutes

Bier Block: What is the minimum amount of time that the TQ must remain inflated following injection of LA?

20 minutes - allows time for LA to absorb into tissue - if cuff deflated too soon, LA washes into systemic circulation, can result in sz or CV collapse

At what level of CBF is there evidence of ischemia?

20mL/100g/min

Subcortical CBF

20mL/100g/min

Each vial of dantrolene contains...

20mg of dantrolene and 3g of mannitol Must be reconstituted with 60mL preservative-free water 20 * 3 = 60

Spinal needle smaller than ___ gauge needs introducer In interspinous ligament to decrease risk of needle deflection

22

When to use an introducer

22g needle or smaller

When should succinylcholine be avoided after SCI?

24 hours after the injury -Fasciculations may worsen SCI -In general, pick a nondepolarizer over succs *Succinylcholine is contraindicated in patients with chronic SCI

Vision loss with ION typically occurs...

24-48 hours after surgery

To reduce the risk of rebleeding, surgical repair of a ruptured aneurysm should take place...

24-48 hours following the initial bleed (makes triple H therapy safer)

A drug has a Vd of 0.5L/kg. In an 85kg patient, what loading dose must be administered to achieve a plasma concentration of 6mg/l?

255mg Loading Dose = (Vd x desired Cp) / Bioavailability Loading Dose = (42.5L x 6mg/L) / 1 = 255mg Bioavailability = 1 since drug is being given IV

Maximal vasoconstriction occurs at a PaCO2 of...

25mmHg Decreased PaCO2 = Decreased CBF d/t vasoconstriction

Pulmonary hypertension is defined as PAP of at least?

25mmHg and a PAOP of no more than 15mmHg

With triple H therapy, what should Hct be reduced to?

27-32%

For every 1 inch above the heart, the real MAP is ___mmHg less than what you see on the monitor

2mmHg

C7 dermatome

2nd and 3rd digit

How many trunks in the brachial plexus and what are they?

3 Trunks: Superior Middle Inferior

How many *cords* are in the brachial plexus?

3 cords: - Posterior (C5-T1)- all posterior--> posterior cord - Lateral (C5-C7)- anterior divisions superior and middle trunk--> lateral cord - Medial (C8-T1)- anterior division of inferior trunk--> medial cord *Divisions turn into cords when brachial plexus goes under pectoralis minor muscle

Within how many hours of an ischemic stroke must TPA be given

3 hours

Optimal depth of catheter insertion

3 to 5 cm

How many *trunks* are in the brachial plexus? What are the corresponding nerve roots?

3 trunks: - Superior (C5-C6) - Middle (C7) - Inferior (C8-T1) *roots turn to trunks just beyond lateral border of scalene muscles

Tx for Eaton-Lambert

3, 4- diaminopyridine (DAP) Anticholinesterases do not help

Treatment of Eaton-Lambert syndrome

3,4-diaminopyridine (DAP) increases ACh release from the presynaptic nerve terminal and improves the strength of contraction **anticholinesterases are NOT helpful and the tensilon test does not dx)

Cerebral metabolic rate for oxygen (CMRO2) number

3-3.8mL/O2/100g/min -CBF is coupled to CMRO2: the higher the need for O2, the more blood flow there will be to satisfy this need

optimal depth of catheter insertion in the epidural space

3-5cm

Production rate of CSF

30mL/hr

Tuohy epidural needle

30° Blunt tip Minimize Risk of dural puncture

Spinal cord has how many paired spinal nerves?

31 paired spinal nerves -Each spinal nerve is formed by a posterior (dorsa) nerve root and anterior (ventral) nerve root. -Posterior nerve roots carry sensory information and anterior nerve roots carry motor and autonomic info

The vertebral column is made up of _____ vertebrae

33 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccygeal

Percentage of patients with SLE that develop the malar "butterfly" rash

33-50%

Protein in CSF vs. plasma

35 in CSF vs. 7000 in plasma

After the patient is stabilized in ICU, be aware that MH may reoccur up to how late?

36 hours later

Active cooling for the MH patient should stop when temp is below:

38c

Mallampati Score of hard palate only

4

How to do a digital nerve block:

4 small nerves innervate each digit -inject 2-3ml of LA at base of both sides of finger- caution arteries are close *NCE dont use epi for these blocks (real life some providers do)

Typical depth of cords

4-5cm

Seizure prophylaxis in the preeclamptic patient begins with magnesium loading dose of

4-6grams IV maintenance 1-g/hr IV target plasma concentration = 2-3.5mEq/L

When is cerebral vasospasm most likely?

4-9 days after SAH

Max does of Lidocaine for peripheral nerve block?

4.5mg/kg or 300 mg

Cobb angle that is indication for surgery

40-50

Cobb angle that indicates need for surgery

40-50 degrees

Hyperthermia beyond what temperature denatures proteins and destroys neurons?

42°C At this point, cerebral blood flow decreases

80kg patient for liposuction. What is the maximum recommended dose of lidocaine for tumescent anesthesia

4400mg

Bier Block: When does TQ pain onset typically begin?

45 - 60 minutes after inflation

Global cerebral blood flow

45-55mL/100g tissue/min

A continuous *femoral n.* block provides analgesia for how long?

48 hours

C8 dermatome

4th and 5th digit

How many *terminal branches* are in the brachial plexus?

5 terminal branches: - musculocutaneous - axillary - median - radial - ulnar

Dose for a bier block

50 mL of 0.5% lidocaine

What 2 changes in somatosensory evoked potential monitoring suggest an increased risk of nerve injury?

50% decrease in amplitude 10% INcrease in latency

At a PaCO2 of 40mmHg, CBF is...

50mL/100g/min

CRNA is using an anesthesia machine that couples fresh gas flow to the tidal volume set on the ventilator. What is the total tidal volume delivered to the patient? Oxygen= 2L/min Air flow= 1L/min Bellows set at 450mL RR = 10 I:E ratio is 1:2

550mL Convert FGF to mL/min = 3000mL/min Multiply FGF by fraction of inspiratory time: 3000 x (1/3) = 1000 Divide by RR: 1000 / 10 = 100mL Add to volume set on bellows

How many oxygen atoms are bound to one hgb molecule when the mixed venous oxygen saturation is 75%?

6

How many *divisions* are in the brachial plexus?

6 divisions: - 3 anterior - 3 posterior * each trunk turns into anterior and posterior division under clavicle and over 1st rib

MH can occur as late as...

6 hours after exposure to a triggering agent

Half life of levodopa

6-12 hours

Draw the brachial plexus

7 cervical vertebra but 8 cervical spinal nerves C8 refers to the nerve

How much does CMRO2 decrease per 1 degree celcius

7% = decreasing CMRO2 makes the brain more tolerant of decreased blood flow (more immune to ischemia) EEG suppression occurs at 18-20 degrees

Keep CPP >_______mmHg

70mmhg

Cortical CBF

75-80mL/100g/min

How soon must surgical decompression be performed for the best chance of recovery from an epidural hematoma?

8 hours

Specificity of the halothane contracture test

80% Risk of a false-negative result

Maximal vasodilation occurs at a PaCO2 of...

80-100mmHg Increased PaCO2 = Increased CBF d/t vasodilation

The grey matter is subdivided into how many laminae?

9

What is the success rate of an EPD blood patch?

90% *if HA does not improve after 2 patches, other etiologies should be sought

Babinski sign with damage to the lower motor neurons

Absent Babinski

Within how much time can a patient receive tPA for an ischemic stroke?

< 3 hours after the onset of symptoms

Cerebral Perfusion Pressure (CPP)

< 50mmHg = vessels are maximally dilated 50-150 = vessel diameter adjusts to keep CBF constant >150 = vessels are maximally constricted

Aortic stensosis is considered severe when aortic valve area is less than

<0.8cm^2

At what level of CBF is there membrane failure and cell death?

<15mL/100g/min

A vital capacity of ______% predicted correlates with requirement for postop ventilation for scoliosis patients

<40% predicted *Assess respiratory reserve with exercise tolerance, ABG, and VC

What GCS is consistent with TBI?

<8

Cerebral hypertension occurs if ICP is...

>20mmHg

intracranial HTN

>20mmHg increased ICP decreased CPP and therefore decreases O2 delivery to the brain. This causes ischemia -> swelling -> decreased CPP -> more ischemia

What vital capacity correlates with requirement for postop ventilation

>40%

Intercostal block technique

A line from T6 to L5 then 5cm from t6 to 7cm to t12 Aim at the rib and very slowly walk of the inferior border inject 3cc per rib( 1.5cc above and 1.5cc below) of .25 bupi

How does a *hypobaric* solution distribute in the *sitting* patient?

A hypobaric sol'n will settle to the highest point of the spinal canal Keep pt sitting - hypobaric sol'n will rise to brain = NOT GOOD

What is the general outline for all blocks?

A.Indication B.(Relative) contraindications: patient refusal, severely demented or combative, coagulopathy, pre-existing hematoma, pre-existing peripheral neuropathy C. Landmarks/Anatomy (VERY IMPORTANT FOR SUCCESS WITH ULTRASOUND-GUIDANCE) D. Muscle stimulation (if using nerve stimulator) E. Amount of drug F. Special consideration/Complications

Hormone produced in the supraoptic nucleus of the hypothalamus

ADH - stimulated by increase in plasma osmolarity(dehydration) the nuclei shrink and stimulates ADH release from posterior pituitary gland

Hormones released by posterior pituitary (2)

ADH and oxytocin

Risks with Marfan's

AI, aortic dissection AAA Cardiac tamponade (if aortic dissection) Mitral prolapse Spontaneous pneumothorax (careful with PIP)

Absence seizure

AKA petit mal Temporary loss of awareness More common in children

Neuraxial recommendations w/ Glycoprotein IIb/IIIa antagonists

Abciximab: b/f block placement hold 1-2 days Tirofiban: b/f block placement hold 8h Eptifibatide: b/f block placement hold 8h

Cranial Nerve VI -Nerve name -Function -Bedside test

Abducens Motor Eye Movement out to sides

Benefits of ultrasound

Ability to see nearby vascular structures Ability to see nerves Ability to visualize the needle approaching the nerve. Ability to see local anesthetic spread. Possibility of reducing complications. Less painful to use Ultrasound instead of nerve stimulator.

How do intracranial tumors, head trauma and volatile anesthetics affect autoregulation?

Abolish/impair autoregulation -CPP dependent on blood pressure

How long does Guillain-Barre persist?

About 2 weeks, with a full recovery in about 4 weeks

Inside the femoral triangle, the femoral n. runs __________________ to the iliopsoas muscle

ANTERIOR

Elderly characteristic associated with greatest risk of 30day mortality? (unplanned ICU admission, emergent surgery, asa 4, acute renal impairment)

ASA 4 status = 12.4% 30day mortality

Treatment for Hyper or Hypokalemic periodic paralysis

Acetazolamide creates non-gap acidosis that counters hypokalemia facilitates renal potassium excretion that counters hyperkalemia

Treatment of familial periodic paralysis for both types:

Acetazolamide (diuretic)- creates non-anion gap acidosis, protecting against hypokalemia, and facilitates renal potassium excretion, guarding against hyperkalemia

Nausea and vomiting from opiates

Activation of opiate receptors in the area postrema of the Medulla and vestibular apparatus

What (3) reduces serum potassium

Albuterol - (B2 agonist) shifts K into cell Insulin - Shift K into liver and skeletal muscle Bowel prep - increases K loss in the feces

Where is the choroid plexus located?

All cerebral ventricles

Fibromyalgia is most closely associated with (neuralgia, dysethesia, allodynia, algesia)

Allodynia - a non-noxious stumulus that produces pain

myasthenia gravis treatment

Anitcholinesterase = oral pyridostigmine is first line tx OD can cause cholinergic crisis and muscle weakness Immunosuppression = steroids, cyclosporine, azothioprine, mycophenolate Surgery = Thymectomy - median sternotomy or transcervical approach Plasmaphoresis = temporary relief during myasthenic crisis or b/f thymectomy

What makes up the anterior and posterior borders of the intravertebral foramina?

Anterior borders: vertebral body and intravertebral discs Posterior borders: fcaet joints

The *femoral n.* provides MOTOR innervation to_______________.

Anterior branch - sartorius Posterior branch - quads

L4 dermatome

Anterior knee

L4 sensory innervation

Anterior knee

Which vertebra does the *lumbar plexus* arise from?

Anterior rami of L1 - L4 (+/- T12)

Which vertebra does the *lumbar plexus* arise from?

Anterior rami of L1 - L4 (occasionally T12)

Where is the *superficial peroneal n.* blocked?

Anterior to the lateral malleolus

Where is the *saphenous n.* blocked?

Anterior to the medial malleolus

What causes SLE symptoms

Antibody induced vasculitis and tissue destruction

Posterior cerebral circulation

Aorta -> Subclavian artery -> vertebral artery -> Basilar artery -> Posterior fossa structures and cervical spinal cord

Anterior spinal artery

Aorta -> subclavian a -> vertebral a -> anterior spinal a Aorta -> segmental a -> posterior radicular a -> anterior spinal a Perfuses the anterior 2/3 of the spinal cord

Posterior spinal arteries

Aorta -> subclavian a -> vertebral a -> posterior spinal a Aorta -> segmental a -> posterior radicular a -> posterior spinal a Perfuses the posterior 1/3 of the spinal cord

Cause of anterior spinal artery syndrome

Aortic cross-clamp above the artery of Adamkiewicz can cause ischemia to the lower portion of the anterior spinal cord

Which valvular disorder is most common in the patient with hx of ankylosing spondylitis?

Aortic insufficiency ankylosing spondylitis is a progressive inflammatory disease

Common cardiac conditions caused by Marfans

Aortic insufficiency & AAA (dilated aortic root), mitral valve prolapse, mitral regurg, aortic dissection, spontaneous pneumothorax is common complication

Side effects of carbamazepine

Aplastic anemia, thrombocytopenia, liver dysfunction, leukopenia, ADH-like effect (hyponatremia)

How does neuraxial anesthesia cause apnea? -What does NOT cause apnea

Apnea is the result of cerebral hypoperfusion -NOT phrenic nerve paralysis or high conc. of LA in CSF -Loss of proprioception input from the chest may cause the patient to complain of dyspnea

Where is cerebrospinal fluid reabsorbed?

Arachnoid villi of the superior sagittal sinus. CSF produced by choroid plexus in all 4 cerebral ventricles at a rate of ~30ml/hr

Cerebellum

Archeocerebellum: Equilibrium Paleocerebellum: regulates muscle tone Neurocerebellum: coordinates voluntary muscle movement

Dermatome

Area of skin innervated by a dorsal nerve root

watershed areas

Areas of the spinal cord that have a single blood supply - particularly susceptible to ischemia

Infraclavicular Block Landmark Image Position of arm

Arm adducted, flexed at elbow with hand resting on abdomen

Supraclavicular indications and Landmarks

Arm, elbow, forearm, wrist, and hand (not shoulder) Landmarks: Subclavian artery (best), clavicle

Where does the *sciatic n.* divide into the *tibial n.* and *common peroneal n.*?

As it passes btwn the major trochanter and the tuberosity of the ischium in the lower 3rd of the thigh

What are the renal and hepatic effects of neuraxial anesthesia?

As long as SBP is maintained, no renal or hepatic blood flow effects

Describe the "triangle" that is formed in the posterior knee for a *popliteal block*

Base = popliteal crease @ knee Apex = convergence of biceps femoris + semitendinosus muscles

Anterior longitudinal ligament

Attached to Anterior surface of the vertebral bodies Extends entire length of spine Attaches to the annulus fibrosis Of intravertebral disc

Tracts in the midbrain

Auditory and visual

How do you prevent central retinal artery occlusion?

Avoid horseshoe headrest- slightest degree of head rotation can compress eye on same side

Anesthetic considerations for familial periodic paralysis (either type) -What 2 things should you avoid?

Avoid hypothermia (even when on CPB) Monitor serum potassium Nondepolarizers are fine in both

Anesthesia considerations with Alzheimer's

Avoid preop sedation, probably not a good candidate for MAC or regional, cholinesterase inhibitors increase DOA of succinylcholine Use short acting drugs to get them back to baseline asap Use glycopyrrolate if an anticholinergic is required- does not cross BBB

Hypobaric solutions (Lighter)

Bupivicaine 0.3% in water Lidocaine 0.5% in water Tetracaine 0.2% in water

Factors that do not significantly affect spread in spinal anesthesia

Barbotage Increased intra-abdominal pressure Speed of injection Orientation of bevel Addition of vasoconstrictor Weight Gender

Epidural veins

Baston's plexus Drain Venus blood from the spinal cord Valveless, Pass through the anterior and lateral regions of epidural space

Anterior spinal artery syndrome is also known as...

Beck's syndrome

Anterior spinal artery syndrome

Becks syndrome Caused by aortic cross-clamp above the artery Adamkiewicz -Flaccid paralysis of the lower extremities -Bowel and bladder dysfunction -Loss of temp and pain sensation -Preserved touch and proprioception

Treatment for post dural puncture headache

Bed rest Hydration nsaids Caffeine Epidural blood patch sphenopalatine ganglion block

Where do upper motor neurons begin and end?

Begin in the cerebral cortex and end in the ventral horn of the spinal cord -Cell bodies originate in cerebral cortex

Where do lower motor neurons begin and end?

Begin in the ventral horn and end at the neuromuscular junction of a muscle -Cell bodies originate in the ventral horn -Lower motor neurons are peripheral motor neurons that link the spinal cord to a muscle

Lower motor neuron

Begins the ventral horn and ends at the NMJ Link the spinal cord to muscles

What muscular diseases are NOT associated w/ MH

Beker muscular dystrophy Neuroleptic malignant syndrome myotonia congenita myotonic dystrophy

When does PaO2 affect CBF?

Below 50-60mmHg will cause cerebral vasodilation and increases CBF (Max vasodilation occurs with PaCO2 80-100 and with CPP <50) -Above 60mmHg it does not affect CBF

(2) descriptions of asynchronous pacing?

Best used for patients with no intrinsic rhythm. Underlying ventricular activity is a risk for R on T phenomenon

Caudal block

Block sacral, lumbar, lower thoracic dermatomes Useful up to a T10 Sensory block

Isobaric solution (Same)

Bupivicaine 0.5% in saline Bupivicaine 0.75% in saline Lidocaine 2% in saline Tetracaine 0.5% in saline

Hyperbaric solutions (Heavier)

Bupivicaine 0.75% in 8.25% dextrose Lidocaine 5% in 7.5% dextrose Tetracaine 0.5% in 5% dextrose Procaine 10% in water

Carbamazepine MOA, metabolism

Blocks voltage gated Na+ channels Membrane stabilizer Hepatic metabolism Hepatic enzyme induction -> resistant to nondepolarizers Also useful for trigeminal neuralgia

Phenytoin MOA, metabolism

Blocks voltage gated Na+ channels Membrane stabilizer Hepatic metabolism Hepatic enzyme induction -> resistant to nondepolarizers Zero order kinetics

Valproic Acid (Depakote) MOA, metabolism

Blocks voltage gated Na+ channels Membrane stabilizer Hepatic metabolism Hepatic enzyme inhibition -> slows phenytoin metabolism

MOA of phenytoin

Blocks voltage-gated sodium channels -membrane stabilizer

Carbamazepine MOA

Blocks voltage-gated sodium channels, membrane stabilizer

MOA of valproic acid

Blocks voltage-gated sodium channels, membrane stabilizer

Causes of increased volume for blood, brain, CSF

Blood: ↑CBF, bleeding Brain: Cerebral swelling, tumor CSF: ↑production by choroid plexus, reduced CSF removal by arachnoid villi, obstruction to reabsorption (infx, bleed, tumor), passage of fluid across the BBB

Sacral cornua

Bony nodules flank sacral hiatus Incomplete development of the faucets

Does ALS affect upper or lower motor neurons?

Both

Cauda Equina s/s

Bowel and bladder dysfxn, sensory dysfxn, weakness +/- paralysis

Muscarinic-2 stimulation causes

Bradycardia M2 receptor slows cardiac conduction

Where do cranial nerves arise from?

Brain and brainstem -12 cranial nerves

What is the cauda equina?

Bundle of nerves extending from conus medullaris to dural sac

Cauda equina

Bundle of spinal nerves extending from conus meddularis to the dural sac

What solutions do you never use with a bier block?

Bupivacaine- difficult resuscitation Epinephrine- ischemia risk Any solution with preservative- risk thrombophlebitis

Deep brain stimulation procedure

Burr hole, insertion of electrodes into the subthalamic nucleus, globus pallidus, and ventralis intermedius- done under sterotactic guidence

3 diseases associated with an increased incidence of malignant hyperthermia

Central core disease Minicore disease King-Denborough syndrome

Subaxial subluxation most commonly occurs at...

C5-C6 *Neck motion can cause SCI *Thoracolumbar spine is generally not affected by RA

Where is the grey matter enlarged in the spinal cord?

C5-C7 - houses cell bodies for neurons that supply the upper extremities L3-S2 - houses cell bodies for neurons that supply the lower extremities

Which nerve roots give rise to each cord?

C5-C7 = LATERAL CORD - ant. div of superior trunk - ant. div of middle trunk C8-T1 = MEDIAL CORD - ant. div of inferior trunk C5-T1 = POST. CORD - post. div of sup. trunk - post. div of middle trunk - post. div of inferior trunk

Which roots give rise to each terminal branch?

C5-C7 = Musculocutaneous C5-C6 = Axillary C5-T1 = Median C5-T1 = Radial C8-T1 = Ulnar

Dermatomes associated with neuraxial anesthetic? C6 - C7 - C8 - T4 - T6 - T10 - T12 - L4 - Face -

C6 - 1st digit (thumb) C7 - 2nd + 3rd digits C8 - 4th + 5th digits T4 - nipple line T6 - xiphoid process T10 - umbilicus T12 - pubic symphysis L4 - anterior knee -Face isn't innervated by a spinal nerve, sensory input is conducted by the trigeminal nerve (CN V)

What vertebral level correlates with the stellate ganglion (cervicothoracic)?

C7

Where is the middle trunk located?

C7

Most common site of a spinal cord injury

C7 Whiplash?

Where is the inferior trunk located?

C8-T1

formula for cerebral blood flow

CBF = Cerebral Perfusion Pressure / Cerebral Vascular Resistance

Critical thresholds for CBF

CBF ~20mL/100g/tissue/min = ischemia CBF ~15mL/100g/tissue/min = complete cortical suppression CBF <15mL/100g/tissue/min = membrane failure & cell death

How does hyperthermia affect the brain?

CMRO2 an cerebral O2 consumption- controlled hypothermia reduces CMRO2

CMRO2 decreases ___% for every 1°C decrease in temperature

CMRO2 decreases 7% for every 1°C decrease in temperature

What nerves control eye movement

CN 3, 4, 6

Which nerves carry pSNS output

CN 3, 7, 9, 10 Oculomotor Facial Glossopharyngeal Vagus Vagus is responsible for 75% of pSNS output

Which cranial nerve is implicated in Bell's Palsy

CN VII: facial ipsilateral facial paralysis

Which cranial nerve is part of the CNS rather than the PNS

CNII: optic meaning it is the only cranial nerve surrounded by dura

What nerve innervates the face (sensory)

CNV: trigeminal

Where does parasympathetic innervation of the gut come from?

CNX - vagus sympathetic innervation comes from sympathetic chain T5-L2

Which laser is most likely to cause corneal injury (Nd:YAG, Argon, CO2, ruby)

CO2 CO2 is long wavelength with absorb more water and do not penetrate deep into tissue, will cause damage to cornea and sclera

Anesthetic mgmt of TBI

CPP > 70mmHg No steroids Avoid prolonged hyperventilation (can worsen cerebral ischemia - only use acutely) Hypertonic fluids Avoid hypotonic solutions & glucose containing solutions (use only for hypoglycemia) Avoid albumin (poorer outcomes) No N2O

What happens if BP is too low?

CPP decreased- autoregulation is often impaired following SAH

Autoregulation range

CPP: 50-150mmHg or MAP: 60-160mmHg CPP = MAP - ICP or CVP (whichever is higher)

CSF reabsorption is dependent on the pressure gradient between ___ and ___

CSF and venous circulation

Blood from SAH can block_____, which causes:

CSF flow which causes hydrocephalus and increased ICP

Major chemical differences between CSF and plasma

CSF has lower potassium, lower PaCO2, lower pH, lower glucose and extremely lower protein content (almost none)

Which anticonvulsant is also useful for trigeminal neuralgia?

Carbamazepine

Embolism also is a big risk for central retinal artery occlusion, which surgery poses the biggest risk?

Cardiac surgery with CPB

A *median n.* block should be avoided in a patient with _____________________.

Carpel Tunnel Syndrome

Effect of phenytoin on NDMBs

Causes hepatic enzyme induction and therefore causes resistance to nondepolarizers (higher dose of NMB)

Effect of carbamazepine on NDMRs

Causes hepatic enzyme induction, and therefore resistance to nondepolarizers

Transient neurologic symptoms

Causes: patient positioning, stretching of sciatic nerve, myofascial strain, muscle spasm Increased risk: Lidocaine, lithotomy position, ambulatory surgery, knee arthroscopy S&S:Severe back and butt pain radiates to both legs Develops within 6 to 36 hours Persist for 1-7 days Treatment: NSAIDs, opioid analgesics, trigger point injections

Which optic arteries are at highest risk of ischemia?

Central retinal and posterior ciliary arteries

Intracranial HTN reduces O2 delivery to the brain. What does this cause (cycle)?

Cerebral ischemia -> cerebral swelling -> decreased CPP -> more ischemia

5 determinants of CBF

Cerebral metabolic rate for oxygen (CMRO2) Cerebral perfusion pressure Venous pressure PaCO2 PaO2

Diseases of the upper motor neuron

Cerebral palsy ALS

Examples of upper motor neuron disease

Cerebral palsy and amyotrophic lateral sclerosis

Causes of increased brain volume

Cerebral swelling Tumor

Cervical & thoracic spinous process directionality vs lumbar spinous process directionality

Cervical & thoracic: angled in a caudal direction Lumbar: posterior direction

What are the 5 divisions of the spinal column? How many vertebrae are present in each?

Cervical (C1-C7) Thoracic (T1 - T12) Lumbar (L1 - L5) Sacral (S1 - S5 - fused) Coccygeal (4 fused = coccyx) *33 vertebrae total

Complete spinal cord injury damages upper/lower neurons -Initial symptoms -After acute phase, what happens?

Complete spinal cord injury damages upper neurons -Initial symptoms: flaccid paralysis, loss of sensation, loss of bowel and bladder function, possibly neurogenic shock -After acute phase: spinal reflexes return and may lead to spasticity

Spinal Anesthesia Spread -Controllable factors (4) -Non-Controllable Factors (2)

Controllable Factors: - baricity of LA - position during + after block placement - dose - site of injection Non-controllable Factors: - volume of CSF - density of CSF

Factors that significantly affect the spread in spinal anesthesiaP

Controllable Factors: -baricity of local anesthesia -patient position -Dose -site of injection Uncontrollable Factors: -Volume of CSF -Density of CSF

Reticular activating system function

Controls consciousness, arousal, and sleep

plica mediana dorsalis

Controversial Band of connective tissue Courses between ligamentum flavum and Dura matter

Neocerebellum

Coordinates voluntary muscle movement -Structure of cerebellum "new movements"

What are the landmarks for infraclavicular block?

Coracoid process, clavicle

Infraclavicular block is what level block?

Cord level

Infraclavicular block level

Cords (posterior, medial, lateral)

What do cords give way to?

Cords give off Branches of nerve terminals

Where do cords turn into terminal branches?

Cords separate into terminal branches in the *axilla*

Most common eye complication in the perioperative period

Corneal abrasion

What are the two classifications of spinal needles?

Cutting tip and pencil point

Intermediate signs of MH

Cyanosis Patient warm to the touch Irregular heart rhythm

Intermediate signs of MH

Cyanosis, patient warm to touch, irregular heart rhythm

Which nerve fibers and tracts are perfused by the anterior blood supply?

Corticospinal tract (flaccid paralysis of lower extremities), Autonomic motor fibers(bowel/bladder dysfunction) Spinothalamic tract (lose pain and temp sensation)

Describe the anatomical position of the The *posterior femoral cutaneous n.*

Courses distally w/ sciatic n. before taking a superficial course as it emerges through piriformis muscle

Anesthetic considerations for MS

Cranial nerve involvement causes bulbar muscle dysfxn -> aspiration risk Hyperthermia & stress can cause exacerbations Succ can cause life-threatening hyperkalemia

What are the 3 types of epidural needles? How do they differ from each other?

Crawford = 0 deg Hustead = 15 deg Tuohy = 30 deg Differ in angle of needle tip. Note the angle inc in alphabetical order!

Aortic dissection least likely to cause aortic insufficiency?

Crawford type 1

in DMD the breakdown of the sarcolemma allows for what markers to circulate?

Creatine phosphokinase and myoglobin to enter circulation

What proteins exit the cells due to the lack of dystrophin

Creatinine phosphokinase and myoglobin

Which disease is cause by a prion? (H1N1, Creutzfeldt-jakob, legionaires, middle east sars)

Creutzfeldt-jakob

Airway complications of SLE

Cricoarytenoiditis - hoarseness, stridor, airway obstruction Recurrent laryngeal nerve palsy

Dystrophin

Critical structural component of the cytoskeleton of skeletal and cardiac muscle cells Helps anchor actin and myosin to the cell membrane

Where do second order neurons of the anterolateral system travel?

Cross to contralateral side of the spinal cord then ascend toward the brain via the anterior spinothalamic tract and lateral spinothalamic tract

Where does the second order neuron of the dorsal column travel?

Crosses to the contralateral side in the medulla, then ascends toward the thalamus via the medial lemniscus

Second order neuron (Anterolateral)

Crosses to the contralateral side of the spinal cord Ascends toward the brain via 2 pathways: anterior spinothalamic & lateral spinothalamic Cell body in the dorsal horn Synapse in the Reticular Activating System or the thalamus

Ventral spinothalamic tract is responsible for what sensation?

Crude touch and pressure

The obturator n. arises from ___________.

L2 - L4

What may be useful for sedation and tremor reduction in a patient with Parkinson's?

Diphenhydramine (Benadryl)

Acceptable response to nerve stimulator (interscalene)

Deltoid (shoulder abduction) Pectoralis major (arm internal rotation) Biceps (forearm flexion) Triceps (forearm extension) Any twitch of the hand or arm

Which part of the neuron receives and processes signals?

Dendrites

Affect of adding opioids to neuraxial block

Denser block -they also diffuse into the systemic circulation and bind to opioid receptors in the body

Define baricity

Density of LA relative to the CSF

What is a dermatome? Myotome?

Dermatome - area of skin innervated by a dorsal nerve root from the spinal cord. Not necessarily the area of skin that is in the same planes a the spinal nerve Myotome - depicts the muscles innervated by the ventral nerve root from the spinal cord

The absence of dystrophin ______ sarcolemma during muscle contraction which _________ membrane permeability

Destabilizes the sarcolemma Increases membrane permeability

What should be done first for a patient experiencing a CVA?

Determine the type via non-contrast CT

Key findings in Alzheimer's

Development of diffuse beta amyloid rich plaques and neurofibrillary tangles in the brain Causes dysfunction synaptic transmission and apoptosis

Most potent glucocorticoid properties (increase in glucose): (aldosterone, prednisone, dexamethasone, methylprednisone)

Dexamethasone

Best antiemetic for patient with prolonged QT interval (droperidol and transdermal scop, ondansetron and droperidol, ondansetron and dexamethasone, scop and dexamethasone)

Dexamethasone and transdermal scopolamine

Dextrose vs water affect on baricity

Dextrose = Increases it (hyperbaric) -> more likely to sink Water = Decreases it (hypobaric) -> more likely to rise saline is generally isobaric

Other than as an anticonvulsant, what is gabapentin useful for?

Diabetic neuropathy, postherapetic neuralgia, reflex sympathetic dystrophy

What causes non-gap metabolic acidosis? (3)

Diarrhea Renal Tubular Acidosis Excessive chloride administration non-gap acidosis is due to loss of HCO3- (or increased Cl-)

Classic problem in Marfan's

Dilated aortic root - aortic insufficiency and aortic dissection

The *obturator n.* provides SENSORY innervation to ___________________.

Distal inner thigh + part of hip

Methods to reduce cerebral edema

Diuretics Hypertonic fluid Corticosteroids (NOT for TBI)

What do divisions combine into?

Divisions combine to form Cords: Lateral, Medial and Posterior

Where do divisions turn into cords?

Divisions converge into cords when BP goes *under the pectoralis minor* muscle

Gabapentin s/e

Dizziness Somnolence Can produce seizure in patients w/ seizure history, need a taper

Duchenne muscular dystrophy

Does not code for dystrophin, which destabilizes the sarcolemma during muscle contraction and increases membrane permeability Extracellular Ca enters the cell, intracellular K exits the cell - can result in hyperkalemic cardiac arrest Myoglobin is free to exit the cell, causing renal failure

Difference of gabapentin compared to other anticonvulsants

Does not induce hepatic enzymes

Parkinson's pathophysiology

Dopaminergic cells in the basal ganglia are destroyed TOO MUCH ACETYLCHOLINE + TOO LITTLE DOPAMINE = overstimulation of basal ganglia Increased Ach in the basal ganglia stimulates GABA activity in the thalamus (suppresses the thalamus) Overactivity of the extrapyramidal system

What is different about the basal ganglia in a patient with Parkinson's?

Dopaminergic neurons are destroyed, favoring a relative increase in cholinergic activity Increased ACh in the basal ganglia increases GABA activity in the thalamus, suppressing the thalamus which suppresses the cortical motor system and motor areas of the brainstem--> results in over activity of extrapyramidal system

Sensory tracts

Doral column: Cuneatus & Gracilis = Fine touch & proprioception Tract of Lissauer: Part of spinothalamic tract Lateral spinothalamic tract: Pain & Temp Ventral spinothalamic tract: Crude touch & pressure

Which column allows for two-point discrimination?

Dorsal column/medial lemniscal system

Where do sensory neurons from periphery enter the spinal cord?

Dorsal nerve root

First order neurons enter the spinal cord via the______. It relays the sensory info from the _______ to the_____

Dorsal root ganglion From dorsal root column to the Medulla

Where are pseudounipolar neurons found?

Dorsal root ganglion and cranial ganglion

Acute treatment of hydrocephalus

Drain placed in lateral ventricles or intrathecal space Draining CSF is most useful when there is an obstruction to CSF, like hydrocephalus.

Forms of skeletal muscle myopathy

Duchenne (most common) Becker, Emery-Dreifuss, facioscapulohumeral, and limb-girdle

Most common form of skeletal muscle myopathy

Duchenne muscular dystrophy -x-linked, recessive disease results from absence of dystrophin protein

Terminal end of subarachnoid space

Dural sack S2 in adult S3 in infants

Phenytoin s/e

Dysrhythmias w/ Hypotension (if rate > 50mg/min) Gingival hyperplasia Aplastic anemia Cerebellar vestibular dysfxn - nystagmus, ataxia Stevens-Johnson syndrome Birth defects

Side effects of phenytoin

Dysrhythmias, hypotension Gingival hyperplasia Aplastic anemia Cerebellar vestibular dysfunction (nystagmus, ataxia) Stevens-Johnson syndrome Birth defects

Amygdala functions

Emotion, appetite, responds to pain and stressors -Structure of the cerebral hemisphere

Neuraxial recommendations w/ low molecular weight heparin

Enoxaparin, Dalteparin, Tinzaparin: b/f block placement (prophylactic dose) hold 12h, (therapeutic dose) hold 24h b/f removing catheter hold 12 h After removing catheter hold 2h

Where do first order neurons of the anterolateral column travel?

Enter through the dorsal root ganglion, ascend 1-3 levels on the ipsilateral side via the Lissauer tract

Which cells form the choroid plexus?

Ependymal cells

What is the primary risk of neuraxial anesthesia in the anticoagulated patient?

Epidural hematoma - can cause paralysis! Risk is similar during block placement and catheter removal

Safety of epidural/spinal with MS

Epidural is safe Spinal may exacerbate symptoms

Which neuraxial opioid can reactivate HSV labialis?

Epidural morphine d/t cephalad spread to trigeminal nucleus presents 2-5 days post-epidural admin *cold sores

Do not use _______ containing solution bc...

Epinephrine; bc risk of ischemic injury

Laws illustrated in the Fick equation (2)

Fick law of diffusion describes transfer rate of gas through a tissue medium Henry - amount of gas that dissolves in solution is directly proportional to the partial pressure of that gas over the solution Graham- rate of gas diffusion is inversely proportional to the square root of its molecular weight

Basal ganglia functions

Fine control of movement -Structure of the cerebral hemisphere "fine control when adding basal to food"

Dorsal column is responsible for for what sensation?

Fine touch and proprioception specific areas are named Cuneatus &Gracillis

Acceptable response to twitch monitor (supraclavicular)

Finger twitch

C6 sensory innervation

First digit thumb

Which types of nerve fibers are blocked first? (Spinal Anesthesia)

First: autonomic fibers Second: sensory fibers Third: Motor neurons

S/Sx of Guillain-Barre

Flaccid paralysis begins in distal extremities and ascends bilaterally (Proximal extremities-->trunk-->face) Intercostal muscle weakness, facial and pharyngeal weakness Paresthesias, numbness, pain

How do you block the *ulnar n.* at the elbow? Volume in ml? Where does it derive from?

Flex elbow 90 degrees Inject btwn *olecranon* + *medial epicondyle* of humerus Volume = 3-5mL -medial cord brachial plexus

Ulnar nerve movement

Flexion of wrist Adduction of all fingers Flexion and opposition of medial two fingers toward thumb [dont worry about thumb movement here]

Hypobaric solution In supine position

Float Towards lower lumbar region

Poiseuille's Law equation= If you triple the radius it will cause flow to increase by a factor of=

Flow = (pi*r^4*change in P) / (8nl) Flow = (3.14 x Radius^4 x pressure difference / 8 x viscosity x length by a factor of 81

Facet joint

Form by the Superior articular process of one vertebrae and inferior Articular process of the vertebrae directly above it Guides And restricted movement of the vertebral column Injury:Can't compress spinal nerveCausing pain and muscle spasm

What are the anatomic boarders of the facet joint? -Facet joint function -Injury to facet join can cause...

Formed by the sup. articular processes of one vertebra and the inf. articular processes of the vertebra directly above -Facet joint guides and restricts movement of the vertebral column -Injury to the facet joint can compress the spinal nerve that exists the respective intervertebral foramina, causing pain and muscle spasm along the associated dermatome

How does blood cause vasospasms in the cerebrum?

Free hgb in contact with outer surface of the cerebral arteries increases risk of vasospasm

Peripheral receptors in the anterolateral system

Free nerve endings Nociceptive receptors

What should be avoided during DBS?

GABA agonists, such as propofol and benzos, because they can interfere with electrophysiologic brain monitoring

GI considerations for DMD

GI hypomotility and impaired airway reflexes= increased risk of pulm aspiration

Neuraxial recommendations w/ Herbal therapies

Garlic, Ginko, Ginseng Proceed if pt not on other blood thinners

GI complications from RA

Gastic ulcerations d/t steroids and NSAIDs

Best options of anesthetic management to prevent autonomic hyperreflexia

General or spinal -Pt does not have sensation below the level of SCI, stimulation to the affected areas can elicit autonomic hyperreflexia. Prevention is key!

Anesthetic mgmt of AH

General or spinal anesthesia is preferred (better than epidural) Epidural can be used for laboring mother but it does not inhibit the sacral root to the same degree Treat HTN w/: removal of stimulus, deepen anesthetic, rapid acting vasodilator (nipride) Treat bradycardia w/ atropine or glyco Do not give chronotropic agents Lidocaine jelly on catheters does not help Succ is contraindicated May present in postoperative period after anesthesia wears off

Trans arterial approach to axillary block

Go THROUGH the artery Inject 40 cc of local - posterior or posterior and anterior to the artery. Apply distal pressure for cephalad spread

Where do you go for the Infraclavicular Block?

Go under the clavicle, lateral to subclavian

Risk factors for Parkinson's

Greatest risk is old age Exposure of manganese (welders), herbicides, pesticides, and possibly genetics

Rounded Bevel tip needle

Greene

The cell bodies form what kind of matter?

Grey matter

Most common cause of acute, generalized paralysis

Guillain-Barre syndrome

GI effects of neuraxial anesthesia -Gut receives parasympathetic innervation from ___, sympathetic innervation from ___ -Inhibition of sympathetic chain causes what? Why?

Gut receives parasympathetic innervation from vagus nerve (CN X), sympathetic innervation from T5-L2 -Inhibition of sympathetic chain between T5-L2 allows unopposed parasympathetic output to the gut and causes sphincters to relax and increases peristalsis "If you had a Take 5 (T5) bar for lunch and are late TWO (L2) dinner you will be running(sympathetic) because of hunger"

s/s intracranial HTN

H/A N/V Papilledema Focal neurologic deficit ↓LOC seizure coma

Methods to increase venous outflow

Head positioning = avoid flexion and extension, avoid head down, head up >30mmHg increases outflow Reduce intrathoracic pressure (PEEP, bucking, coughing, straining)

What are the clinical implications of phrenic nerve paralysis?

Healthy patients: NBD COPD patients: - severe dyspnea - hypercapnia - hypoxemia

A alpha peripheral nerve fibers

Heavy myelinated Function: skeletal muscle, Motor proprioception diameter: 12 to 20 µm Velocity: Very high Block of onset: fourth

A beta peripheral nerve fibers

Heavy myelination Function: touch, pressure In diameter: 5 to 12Micrometers Velocity:Moderately high Block onset: fourth

A-beta Nerve Fiber -Myelination -Function -Diameter -Conduction velocity -Block onset

Heavy myelination Function: Touch, Pressure 5 - 12 ++++ 4th Beta men are always trying to touch you and pressure you into stuff.

Complications with axillary block:

Hematoma if using transarterial approach LA toxicity if injected into artery

Neurogenic shock

Hemodynamic derangement associated with spinal cord injury instability is greatest with injuries to the cervical or upper thoracic cord. the higher the injury the greater the degree of instability Can be confused w/ hypovolemic shock

If endovascular coil is placed what will the patient require?

Heparinization

Side effects of valproic acid

Hepatotoxicity Thrombocytopenia - increased surgical bleeding, especially in kids

Epidural morphine it may react to with:

Herpes simplex Labialis cephalad spread of morphine on trigeminal nucleus 2 to 5 days after epidural morphine admin

Subdural space

High spinal with epidural dose Failed spinal with spinal dose

Effect of high venous pressure on the brain

High venous pressure decreases cerebral venous drainage, increasing cerebral volume (ICP)

The level of sensory blockade is _______ than motor block (Spinal Anesthesia)

Higher 2 dermatomes higher than motor

*Hydrophilic* Opioids: Nausea + vomiting

Higher incidence

*Hydrophilic* Opioids: Pruritus

Higher incidence -Histamine release with these drugs

The *obturator n.* is prone to injury during extensive _________________ surgery.

Hip

The *obturator n.* provides MOTOR innervation to ___________________.

Hip ADDuctors

Obturator n. MOTOR innervation: Sensory innervation:

Hip ADDuctors Distal inner thigh + part of hip

Deep brain stimulation for Parkinson's

Hold levodopa to allow for better mapping Burr hole awake, lightly sedated (do not use GABA agonists - precedex, opioids) precordial doppler for air embolism d/t sitting position SBP < 140

Cauda equina

Horses tail bundle of spinal nerves extending from conus medullaris to dural sac

How does lipophilicity affect rostral spread in the subarachnoid space?

Hydrophilic drugs tend to remain in the subarachnoid space and travel toward the brain (rostral spread) Lipophilic drugs tend to diffuse out of the subarachnoid space and enter the systemic circulation

Which are more likely to remain in the CSF? sufentanil, hydromorphone, meperidine, fentanyl

Hydrophillic opioid remains in the CSF and achieves a higher level of block. Meperidine, hydromorphone,

Hyperbaric is in what solution? (except what?) Isobaric is in what solution? Hypobaric is in what solution?

Hyperbaric- dextrose (except 10% procaine in water) Isobaric- saline Hypobaric- water

Conditions that increase specific gravity

Hyperglycemia uremia High protein content Advanced aged Colder temperature

Conditions that increase specific gravity

Hyperglycemia Uremia High protein content Advanced age Colder temperature

What side effect from corticosteroids is associated with worse outcomes?

Hyperglycemia -Hyperglycemia during cerebral ischemia is associated with worse outcomes

Blood sugar during stroke

Hyperglycemia = glucose is converted to lactic acid during ischemic stroke which causes acidosis which destroys brain tissue

Conditions to avoid post CVA

Hyperglycemia and hyperthermia

Stroke RF

Hypertension (most important) Smoking DM HLD Excessive alcohol intake elevated homocysteine levels

Classic presentation of autonomic hyperreflexia

Hypertension and bradycardia

Cushing's triad -What is it a sign of? -How are these symptoms produced?

Hypertension, bradycardia, irregular respirations -Sign of intracranial HTN -Increased ICP reduces CPP. To preserve cerebral perfusion the BP is increased. Increased BP activates baroreceptor reflex and causes bradycardia. The medulla compensates for bradycardia and causes irregular respirations

Late signs of MH

Hyperthermia Cola-colored urine Coagulopathy Muscle rigidity

CMRO2 is increased by...(4)

Hyperthermia Seizures Ketamine Nitrous oxide

Effect of fluids: Hypertonic Hypotonic Glucose containing Albumin

Hypertonic: restores intravascular volume and decreases brain water Hypotonic: AVOID- increases cerebral edema Glucose containing: worsen neuro outcomes in setting of cerebral ischemia (only reserve for hypoglycemic) Albumin: linked to poor outcome

Methods to ↓ CBF

Hyperventilation (↓PaCO2 ~30-35mmHg) Avoid hypoxemia (keep PaO2 > 60mmHg Avoid vasodilators (NTG, nipride) Drugs that reduce CMRO2 are ok (thiopental, propofol) Avoid extreme HTN - BP above the autoregulation curve contributes to edema

What should you specifically avoid in a patient with a TBI? (2)

Hyperventilation - can worsen cerebral ischemia Steroids- worsen neurologic outcome- increased glucose--> glucose--> lactic acid

Cardiovascular complications associated with acute pancreatitis include all of the following except: (myocardial depression, pericardial effusion, thrombophlebitis, hypervolemia)

Hypervolemia

*What is the triple H therapy for vasospasm?

Hypervolemia, hypertension, hemodilution (Hct 27-32) liberal hydration supports BP, hemodilution decreases blood viscosity *note little evidence*

What are the landmarks to look for when using the ultrasound?

Hypoechoic pulsating subclavian artery (superior to first rib)

Cranial Nerve XII -Nerve name -Function -Bedside test

Hypoglossal Motor Tongue movement

If ICP is normal (__-___), MAP must be ___ to ensure a CPP of 50mmHg. -Elevated ICP requires a higher/lower MAP for perfusion

If ICP is normal (5-15), MAP must be 55-65 to ensure a CPP 50mmHg. Elevated ICP requires a higher MAP for perfusion -LARGE patient to patient variability

Which nerve roots give rise to the *lateral femoral cutaneous nerve*?

L2 + L3

Anesthetic implications for hypothyroid patients

Hypotension Aspiration- 2nd to decreased gastric emptying Does NOT affect MAC, but changes in CO affect the FA/FI relationship and speed of anesthetic induction.

What is the primary neurohumoral organ? What does it do?

Hypothalamus Regulates body temp thirst/appetite/wt control sleep cycles BP/HR

CMRO2 is decreased by... (5)

Hypothermia Halogenated anesthetics Propofol Etomidate Barbiturates

Temp control for periodic paralysis

Hypothermia must be avoided at all costs Pt's are kept normothermic even during CPB

Which laminae are sensory?

I - VI

Cranial Nerve Functions

I. (Olfactory) Some: Sensory Function II. (Optic) Say: Sensory Function III. (Oculomotor) Money: Motor Function IV. (Trochlear) Matters: Motor Function V. (Trigeminal) But: Both Sensory and Motor Function VI. (Abducens) My: Motor Function VII. (Facial) Brother: Both Sensory and Motor Function VIII. (Vestibuloclear) Says: Sensory Function IX. (Glossopharyngeal )Big: Both Sensory and Motor Function X. (Vagus) Brains: Both Sensory and Motor Function XI. (Accessory) Matter: Motor Function XII. (Hypoglossal) More: Motor Function

functions of CN III, IV, VI

III: Eye movement (all except cross eyed and lateral) & pupil constriction IV: Eye movement (cross eyed) VI: Eye movement (lateral)

Inside th femoral triangle, the femoral n. runs ________________ to the fascia lata and fascia iliaca

INFERIOR

Inside the femoral triangle, the femoral n. runs ________________ to the fascia lata and fascia iliaca

INFERIOR

Which nerve roots give rise to the *femoral nerve*?

L2 + L3 + L4

How does N2O cause central retinal artery occlusion?

If nitrous gets used following retinal detachment surgery with intraocular bubble placement

Kidney and liver effects of neuraxial analgesia

If systemic blood pressure maintained, hepatic and renal bloodflow unchanged

Pathophysiology of myasthenia gravis

IgG antibodies destroy post-junctional, nicotinic, acetylcholine receptors at the NMJ *Ach is present, but not enough receptors to translate signal to intracellular response so you get skeletal weakness G for ground

What is Eaton-lambert syndrome caused by?

IgG mediated destruction of presynaptic Ca+ channels at the presynaptic terminal "EL"- elevator upper NMJ Myasthenia Gravis -"Ground" lower NMJ

6 nerves that arise from the lumbar plexus "I Instantly Get Lazy On Fridays

Iliohypogastric Ilioinguinal Genitofemoral Lateral femoral cutaneous Obturator Femoral

Name the 6 terminal branches of the *lumbar plexus*

Iliohypogastric - I Ilioinguinial - Invariably Genitofemoral - Get Lateral femoral cut. - Lazy Obturator - On Femoral - Fridays

*Lumbar Plexus* Primary Nerves

Iliohypogastric n. Ilioinguinal n. Genitofemoral n. Lateral femoral cut. n. Obturator n. Femoral n.

What do you do if the aneurysm ruptures during the procedure?

Immediately reverse heparin with 1mg protamine for every 100U of heparin given MAP should be low end normal *Adenosine can be given to temporarily arrest heart so interventional radiologist can control bleeding

Guillain-Barre

Immunologic deterioration of myelin in the peripheral nerves- action potential can't be conducted so motor endplate doesn't receive the incoming signal

Which option can be a source of coagulopathy (VitK supplementation, increased cholecystokinin, sphichterotomy of the sphincter of Oddi, impaired bile production)

Impaired bile production Impaired bile production reduced absorptiono f vitamin K. Vitamin K is important in producing factor 2,7, 9, 10

EKG changes with DMD

Impaired cardiac conduction -> ST & short PR interval Increased R wave amplitude in lead I and deep Q waves in the limb leads

Pathophysiology of neurogenic shock

Impairment ot cardioaccelorator fibers (T1-T4) Decreased SNS tone -> vasodilation -> venous pooling -> decreased CO & BP Impairment of sympathetic pathways from hypothalamus to blood vessels -> inability to vasoconstrict or shiver -> hypothermia

What diameter needle is helpful in an in plane approach?

In Plane approach: A larger diameter needle can be helpful, especially if the nerve is relatively deeper, and a longer needle is required.

Gastrointestinal effects of neuraxial analgesia

Inhibition of sympathetic chain between a T5 to L2 Allows parasympathetic outputTo function unopposed Causes of sphincters to relax and increases peristalsis

How do you block the *median n.* at the forearm? Volume in ml? Where does it derive from?

In the AC fossa, inject *medial to brachial a.* (brachial artery is medial to biceps tendon) Volume = 3-5mL lateral and medial cord of BP

Where do first order neurons of the anterolateral system synapse with second order neurons?

In the dorsal horn laminae I, IV, V, and VI

Where do first order neurons of the dorsal column synapse with the second order neuron?

In the medulla (cuneate (upper limbs) and gracile (below T6-lower limbs nuclei are first order neurons carry the signal)

When is weakness worst with Eaton-Lambert syndrome?

In the morning Gets better throughout the day "eating breakfast is hard in the morning"

Where do second order neurons of the anterolateral system synapse?

In the reticular activating system (pain signals) and the thalamus (tactile signals)

Where do second order neurons of the dorsal column synapse with third order neurons?

In the thalamic relay station - ventrobasal complex

What is the risk of neuraxial technique in a pt w/ inc. ICP?

Inc. risk of brain herniation w/ sudden changes in CSF pressure

Parkinson's treatment

Increase dopamine levels or decrease Ach in basal ganglia levodopa (L-dopa/ Sinemet) & Carbadopa Levodopa is metabolized to DA in the blood and cannnot cross the BBB. Carbadopa is a decarboxylase inhibitor so it inhibits the metabolism of levodopa to DA, allowing levodopa to make it into the brain

Methods to decrease CSF

Increase drainage (Ventric) Acetazolamide and lasix decrease CSF production

Monro-Kellie hypothesis

Increase in volume of one component (brain, blood, CSF) must be compensated by a decrease in volume of another, or pressure inside the cranium will rise

When Levodopa and carbidopa are given together they:

Increase the concentration of dopamine at the basal ganglia

Causes of increased blood volume

Increased cerebral blood flow Bleeding

Side effects of levodopa and carbidopa

Increased inotropy, tachycardia, orthostatic hypotension Dyskinesia, nausea, vomiting

If an RSI is required in a patient with myasthenia gravis, how should you dose succinylcholine?

Increased resistance Increase to 1.5-2mg/kg

Other Anesthetic considerations with Guillain-Barre

Increased risk of aspiration, may need postop ventilation Risk for hemodynamic instability (position changes, anesthetics, PPV, blood loss) Exaggerated response to indirect-acting sympathomimetics d/t upregulation of postjunctional adrenergic receptors *regional anesthesia is controversial *steriods not useful

What happens if the BP is too high post op aneurysm repair?

Increased transmural pressure and risk of rebleed

Why should PaCO2 not be reduced to lower than 30mmHg?

Increases the risk of cerebral ischemia d/t vasoconstriction and left shift in oxyhgb curve which causes reduced O2 offloading

Opioids have an antidiuretic effect by:

Increasing Vasopressin release

SLE exacerbation

Induced by stress or drug exposure PISSED CHIMP P = Pregnancy I = Infection S = Surgery S = Stress E = Enalapril D = D-penicillamine C = Captopril H = Hydralazine I = Isoniazid M = Methyldopa P = Procainamide

Major causes of morbidity and mortality in patients with cervical and upper thoracic SCI

Ineffective alveolar ventilation and inability to clear pulmonary secretions

What procedures work best with an *infraclavicular block*?

Infraclavicular approach is a cord level block Best for procedures BELOW elbow

What is malignant hyperthermia?

Inherited disease of skeletal muscle that involves disordered Ca+ homeostasis

Complications of Axillary Block

Intravascular injection Hematoma Inadequate anesthesia of the musculocutaneous nerve*****

Gold standard of ICP measurement

Intraventricular catheter -ICP can also be measured with a subdural bolt or a catheter placed over the convexity of the cerebral cortex

Which nerve roots give rise to the *obturator nerve*?

L2 + L3 + L4

What can be added to the LA to assist with postoperative analgesia?

Ketorolac (15-30mg) *does not increase the risk of bleeding

The *lateral femoral cutaneous n.* arises from ________________.

L2 - L3

The *femoral n.* arises from __________.

L2 - L4

The *obturator n.* arises from ___________.

L2 - L4

Which organ is most susceptible to cyclosporine toxicity

Kidney cyclosporine is a calcineurin inhibitor. Calcinuerin inhibitors reduce GFR by causing profound vasoconstriction of the afferent arteriole

MH is linked to 3 other co-existing diseases:

King-Denborough syndrome Central core disease Multiminicore disease *possibly hypokalemic periodic paralysis

In 10% of the population, the artery of Adamkiewicz originates between...

L1-L2

INFANT Conus Medullaris

L3

Which spinal level is designated by the intercristal line?

L4 A horizontal line drawn across the superior aspects of the iliac crest designates the intercristal or Tuffiers line.

The *sciatic nerve* arises from _____________.

L4 - S3

Which vertebrae does the *sacral plexus* arise from?

L4 - S4

Which vertebrae does the sacral plexus arise from?

L4 - S4

Tuffier's Line

L4-L5 interspace (correlates with the iliac crest)

Which spinal nerves are most resistant to local anesthetics

L5 & S1 = largest nerves It is also the largest interspace

What does it mean if an LA is *hyperbaric*?

LA has higher density vs. CSF Solutions in dextrose = hyperbaric Hyperbaric solution will SINK

What does it mean if an LA is *hypobaric*?

LA has lower density vs. CSF Water Hypobaric solution will RISE

What does it mean if an LA is *isobaric*?

LA has similar baricity to CSF Solutions in saline = isobaric Isobaric solution will remain where it is injected

biggest concern with any block is?

LAST (local anesthetic systemic toxicity)

The *lateral femoral cutaneous n.* provides SENSORY innervation to:

LATERAL THIGH

All of the following are anesthetic considerations for the patient with a tonsilar bleed except (LMA, requires RSI, volume restricted before induction, hemorrhage most commonly occurs within 24hours of surgery)

LMA LMA is actually contraindicated

*Hydrophilic* Opioids: How long do they stay in CSF?

LONGER period of time vs. lipophilic

This cord gives off a branch of the median nerve and ends as the musculocutaneous

Lateral cord

Lateral corticospinal tract -What does it innervate -Where does it cross over

Lateral corticospinal tract: Fibers that innervate the limbs cross over to the contralateral side in the medulla -From here, they descend the spinal cord via this tract. Synapse in the ventral horn to the limb muscles "Lateral: LiMbs (limbs and medulla)"

Motor tracts

Lateral corticospinal tract: Limb motor Ventral corticospinal tract: Posture motor

What position does the patient need to be in for the psoas block?

Lateral decubitus with side to be blocked in non-dependent position- be able to easily visualize the quadriceps muscle

Caudal technique

Lateral or prone Sims position Landmarks: iliac spines & sacral hiatus 22-25g needle, 20g IV Placing needle above S2-3 increases risk of dural puncture Do not use air for loss of resistance (air embolism)

Flow of CSF

Lateral ventricles Foramen of Monro 3rd ventricle Aqueduct of Sylvius 4th ventricle Foramen of Luschka and Magendie Subarachnoid Space Superior sagittal sinus/arachnoid villi "Love My 3 Silly 4 Lorn Magpies"

How does a *hyperbaric* solution distribute in the *supine* patient?

Lay down after block - hyperbaric sol'n will slide down lumbar lordosis and eventually pool in *sacrum* and *thoracic* kyphosis (T4)

How does a *hypobaric* solution distribute in the *supine* patient?

Lay down after block - sol'n will float toward lumbar region DOES NOT float toward cervical region, b/c that would 1st require LA to sink into thoracic kyphosis

What lead is best for diagnosing dysrhythmias?

Lead II

What medications are typically used for an interscalene block?

Lidocaine 1-1.5%, Bupivacaine .2-.375%, Ropivacaine .2-.5, Mepivicaine 1%

Where does the artery of Adamkiewicz most commonly originate?

Left side between T11-T12 11 letters in adamkiewicz

*Hydrophilic* Opioids: Systemic absorption

Less (this is why it stays in CSF longer)

The three terminal nerves of the hand can be blocked at what 2 places?

Level of the forearm or wrist- useful for surgery on forearm/hand or for rescue block of a nerve that was missed during BP block ** these are good hotspot questions***

Treatment for Parkinson's

Levodopa/carbidopa Selegiline Dopamine agonists Anticholinergics COMT inhibitors (catechol-o-methyltransferase) Amantadine Hormone replacement

B Nerve Fiber -Myelination -Function -Diameter -Conduction velocity -Block onset

Light myelination Function: Preganglionic ANS 3 ++ 1st

B peripheral nerve fibers

Lightly myelinated Function: Preganglionic ANS fibers Diameter: 3 µm Velocity: second slowest Block onset: first

Lateral corticospinal tract is responsible for:

Limb motor

Respiratory depression caused by: Lipophillic opioids: More quickly absorbed by the _______ tissue, which limits amount of _______. In the epidural space, ________ a lipophilic drug in ______cc of preservative free Nacl will _______ spread. Early phase resp depression results from: Late phase?

Lipophillic opioids: More quickly absorbed by the spinal tissue, which limits amount of spread. In the epidural space, diluting a lipophilic drug in 10cc of preservative free Nacl will enhance spread. Early phase: results from systemic absorption Late phase? no late phase

Conditions and decreases specific gravity

Liver disease jaundice Warmer temperature

Conditions that decrease specific gravity

Liver disease Jaundice Warmer temperature

What is the main risk of a Bier block?

Local anesthetic toxicity

Focal cortical seizure

Localized to a particular focal region -Can be sensory or motor -usually no LOC

What will you see on the screen with long axis imaging?

Long access will see everything axis Ex: if doing an US on radial artery, will show up as a LINE

what will you see in a block/lesion to the median nerve ?

Median (C 5 -T1) at Elbow. Pronation of radioulnar joints. *"Ape Hand"*- thumb hyper extended and adducted - thenar muscles. Weakened opposition of thumb - thenar muscles. Sensory Deficit-Radial portion of palm; palmar surface & tips of radial 31/2 digits [a lot times injury is due to antecubital IV sticks]

This nerve is derived from both the lateral and medial cords. Motor innervation is to most of the flexors muscles in the forearm and intrinsic muscles of the thumb (thenar muscles). Sensory innervation is from the lateral ( radial) 3 & 1/2 digits ( the thumb and first 2 and 1/2 fingers).

Median nerve [Unopposable thumb. 'Ape hand']

A gamma peripheral nerve fibers

Medium myelination Function: skeletal muscle tone Diameter: 3 to 6 µm Velocity: Medium Block onset: third

A-delta Nerve Fiber -Myelination -Function -Diameter -Conduction velocity -Block onset

Medium myelination Function: Fast pain, Temperature, Touch 2 - 5 +++ 3rd Delta flight, how lucky am I? A *medium*-sized person is to my right. *2-5* hours, no room for my feet, my neck hurts (pain), I'm cold (temp), this kid won't stop *touching* my seat. *3rd* to depart, it breaks my heart...oh when oh when will my vacation start?

A-gamma Nerve Fiber -Myelination -Function -Diameter -Conduction velocity -Block onset

Medium myelination Function: Skeletal muscle - tone 3 - 6 +++ 3rd

Which peripheral mechanoreceptors are responsible for two-point discriminative touch and vibration?

Meissner's corpuscles *Double Es for two point discrimination and double S for vibration*

Dorsal column peripheral receptors

Meissner's corpuscles= 2 point discriminative touch, vibration Merkel's discs= Continuous touch Ruffini's Endings= proprioception, prolonged touch and pressure Pacinian corpuscles= vibration

Hippocampus functions

Memory and learning -Structure of the cerebral hemisphere "University campus for memory and learning"

Which peripheral mechanoreceptors are responsible for continuous touch?

Merkel's discs *Angela Merkel is continuously in power

In patients with seizure disorders, what drugs increase EEG activity and can help determine the location of seizure foci during cortical mapping?

Methohexital, etomidate, and alfentanil

4 structures in the brainstem

Midbrain Pons Medulla Reticular activating system

Brainstem

Midbrain: auditory and visual tracts Pons: autonomic integration Medulla: autonomic integration Reticular activating system: controls consciousness, arousal, and sleep

effect of epidural opioids on breast milk

Minimal

Systolic murmur heard over 5th intercostal space and MCL. What type of valvular disease would one expect?

Mitral regurgitation

What (2) increase after placement of an infra-renal aortic cross clamp?

Mixed venous oxygen saturation Preload

*Lipophilic* Opioids: Systemic absorption

More

Urinary retention with opioids

More common in young males More common with neuraxial opiates Inhibition of sacral parasympathetic tone Bladder detrusor muscle relaxed, urinary sphincter contracts Reversed with the naloxone

From most Hydrophilic to Lipophilic opioids

Morphine > Hydromorphone > Meperidine > Fentanyl > Sufentanil

Branches

Most Alcoholics Must Really Urinate Musculocutaneous: C5-C7 -> lateral cord Axillary: C5-C6 -> Posterior cord Median: C5-T1 -> Lateral & medial cord Radial: C5-T1 -> Posterior cord Ulnar: C8 - T1 -> Medial cord

What is the primary determinant of spread for epidural anesthesia?

VOLUME

Corticospinal tract (Motor)

Most important motor pathway Also known as the pyramidal tract Pyramids are formed by the corticospinal neurons as they run through the medulla All toher motor tracts are called extrapyramidal b/c they don't pass through the pyramids

Artery of Adamkiewicz

Most important radicular artery Perfuses the anterior spinal cord in the thoracolumbar region Most commonly originates on the left side b/w T11-12 In 75% of the population it arises from T8-12 In another 10% it arises from L1-2

what is the interscalene block used for?

Most suitable for procedures on the upper arm or shoulder

Volatile anesthetics usually provide enough:

Muscle relaxation for procedures- working on ventral

Late signs of MH

Muscle rigidity, cola-colored urine, coagulopathy, irregular heart rhythm

Myotome

Muscles innervated by ventral nerve roots

Which nerve is most likely to be missed with an axillary block?

Musculocutaneous

what will you see in a block/lesion to the Musculocutaneous nerve ?

Musculocutaneous C 5,6,(7)Very weak flexion of elbow joint- Biceps & Brachialis. Sensory deficit-Lateral Forearm *"unmuscular"*

This nerve is derived from the lateral cord. This nerve innervates the muscles in the flexor compartment of the arm. Carries sensation from the lateral (radial) side of the forearm.

Musculocutaneous nerve [allows you to flex]

The _______________ nerve is most likely to be missed during an *axillary block*.

Musculocutaneous nerve (most often needs to be blocked separately)

Eaton-Lambert syndrome is also called...

Myasthenic syndrome and Lambert-Eaton myasthenic syndrome (LEMS) *Boards will try to confuse you with terms- don't confuse this with myasthenia gravis*

Spinal anesthesia site of action

Myelinated preganglionic fibers of the spinal nerve roots superficial layers of the spinal cord

When used as part of a balanced anesthetic, cardiovascular effects of nitrous oxide include (2)?

Myocardial depression Increased BP (activates SNS, increases SVR, BP, HR)

What does etomidate cause?

Myoclonus, but not asso. with increased EEG activity in pts that don't have epilepsy

Bier Block: < 20 min since LA injection. Can you deflate cuff?

NO

Is a *spinal* safe in the patient w/ MS?

NO SAB = symptom exacerbation in MS patient

Do neuraxial opioids cause: - sympathectomy? - skeletal muscle weakness? - changes in proprioception?

NO to all!

The *saphenous n.* provides MOTOR innervation to what structures?

NONE

Hydromorphone Intrathecal dose: Epidural dose: Epidural Infusion dose:

NOT APPLICABLE 0.5 - 1 mg 0.1 - 0.2 mg/hr

Anesthetic considerations hypokalemic periodic paralysis What not to administer? What is okay to administer?

NOT:Avoid glucose-containing solutions, potassium-wasting diuretics, and beta-2 agonists Okay: **Succinylcholine, NDNMB, Acetazolamide ** controversial- not bc of a K+ shift, but bc there is a possible link between hypokalemic PP and malignant hyperthermia

The *lateral femoral cutaneous n.* provides MOTOR innervation to _____________.

NOTHING

The *posterior femoral cutaneous n.* provides MOTOR innervation to ____________

NOTHING

Channel dysfxn associated w/ Hyperkalemic periodic paralysis

Na+ channelopathy

Neck complications with prone position and scoliosis

Neck rotation -> vertebral compression -> cerebral hypoperfusion

Field Block of musculocutaneous

Needle: 22g, 1 ½ inch Insert needle above artery towards coracobrachial muscle (pinch the belly) Illicit parasthesia (bicep) 5-8cc of local

Neurogenic shock VS Hypovolemic shock

Neurogenic: bradycardia, HoTN and pink/warm extremities Hypovolemic: tachycardia, HoTN and cool/clammy extremities

What is the functional unit of the nervous system? -Primary role?

Neuron - receives and sends information

The brain is made up of 2 types of cells. What are they?

Neurons and Glial cells

What causes cauda equina syndrome (CES)?

Neurotoxicity is the result of exposure to *high concentrations* of LA

What is the only CCB shown to reduce M+M with vasospasm?

Nimodipine Does not relieve the spasm - increases collateral blood flow

Vasospasm prevention / treatment

Nimodipine Triple H therapy: hemodilution (HCT 27-30), hypervolemia, hypertension) daily transcranial doppler exams Maintain CPP Liberal hydration: supports MAP & CPP, causes hemodilution which decreases blood viscosity and cerebrovascular resistance

Bourdon pressure gauge can be used to calculate the cylinder volume for (2)

Nitrogen and helium - they exist as gas in the cylinder

Is there an increased risk of MH w/ osteogenesis imperfecta?

No

Is there 2 point discrimination with the anterolateral system?

No medial leminiscal is two point discrimination

Is Horner's Syndrome a bad thing?

No - it indicates a successful block

C dorsal root peripheral nerve fibers

No Myelination Function: slow pain, Temperature, touch diameter: 0.4 - 1.2 µm Velocity: slowest Block onsets: the second

epidural differential block

No autonomic differential block sensory is 2-4 dermatomes higher than motor

C Nerve Fiber (dorsal root) -Myelination -Function -Diameter -Conduction velocity -Block onset

No myelination Function: Slow pain, Temperature, Touch 0.4 - 1.2 + 2nd Damn (Dorsal and Delta go together) I'm not flying Delta - Slow flight, Cold flight, Touching me

A patient with minor head trauma does not require a head CT if they meet what criteria?

No physical evidence of trauma above clavicles, no headache, no N/V, no neuro deficit, no intoxication or seizures, age <60

Guillain-Barre Anesthetic mgmt

No succ - risk of hyperkalemia Increased sensitivity of nondepolarizers ANS dysfxn -> hemodynamic instability exaggerated response to indirect sympathomimetics (upregulation of postjunctional adrenergic receptors) Immobility -> increased risk of DVT Regional anesthesia is controversial

Should you withdraw the catheter through the epidural needle?

No, it can shear the catheter leaving fragments inside the pt

Is supraclavicular block associated with phrenic nerve involvement?

No.

s/s of toxicity

Numbness of Mouth/tongue Lightheadedness Tinnitus Visual disturbances Irrational behavior Muscle twitching Unconsciousness Generalized Convulsions Coma Death

myasthenia gravis

Normal Ach production, autoimmune related antibodies (IgG) destroy receptors on the neuromuscular jxn Symptoms become worse later in the day or w/ exercise, get better w/ rest thymus gland plays a key role and its removal can improve condition

Number and label cranial nerves

Numbers and Names

Which muscles are not affected in ALS?

Ocular muscles Sensation remains intact

Cranial Nerve III -Nerve name -Function -Bedside test

Oculomotor Motor Eye movement and pupil constriction 3 - eye lashes so all movement

What is the interscalene groove?

On lateral border of sternocleoidmastoid muscle

What ligaments are transversed w/ the paramedian approach

Only the ligamentum flavum

Which (3) axes must be aligned to ensure the best chance for successful laryngoscopy and intubation?

Oral (OA) Pharyngeal (PA) Laryngeal (LA)

What CANNOT treat PDPH?

Opioids

Cranial Nerve II -Nerve name -Function -Bedside test

Optic Sensory Vision

Cranial nerve most likely to be affected by a pituitary tumor

Optic nerve

Side effects of levodopa

Orthostatic hypotension. Common early in therapy

Does the needle size matter in the out of plane approach?

Out of plane approach: Needle diameter would not matter, since the needle is not visualized with this technique

What area of the EKG conicides with the "a" wave of the CVP waveform?

P wave respresents atrial depolarization. The "a" wave on CVP represents atrial contraction

Boyle's Law

P1V1=P2V2 temperature is constant volume and pressure are indirectly proportional to each other

What is the one exception of hyperbaric solutions containing dexrose?

PROcaine 10% in water (lots of molecules)

Which lab value is prolonged in the patient with hemophilia A?

PTT only. Factor 8 deficiency

PaO2 effect on CBP

PaO2 < 50-60mmHg causes cerebral vasodilation and increases CBF (edema). When PaO2 is > 60mmHg it has no effect on CBF

Which peripheral mechanoreceptors are responsible for vibration only?

Pacinian corpuscles "pacific ocean earthquake vibrations"

Lateral spinothalamic tract is responsible for what sensation?

Pain and temperature

Doppler ultrasound technique for supraclavicular block

Palpate the Subclavian artery or position the ultrasound probe at the middle of the clavicle find the artery on Ultrasound just lateral will see a bundle of grapes then BAM.

LOWER Risk Factors for PDPH

Patient Factors - old - non-pregnant - male Provider Factors - pencil-point tip needle - small diameter needle - one dural puncture - using fluid for LOR needle parallel to long axis of meninges - continuous spinal cath (if placed after wet tap)

Artery of Adamkiewicz where does it perfuse? (most important)

Perfuses the anterior spinal cord in the thoracolumbar region

RA cardiac complications

Pericardial effusion or tamponade Aortic regurgitation d/t dilated Aortic root Valvular fibrosis Coronary artery arteritis

Cardiac complications of RA

Pericardial effusion or tamponade Restrictive pericarditis Aortic regurg Valvular fibrosis Coronary artery arteritis

CV complications of SLE

Pericarditis Raynaud's syndrome Hypertension Conduction defects Endocarditis

CV complications of SLE

Pericarditis (tamponade is uncommon) Raynaud's HTN Conduction defects Endocarditis

Nervous system complications from RA

Peripheral neuropathy d/t nerve entrapment

Nervous system complications of RA

Peripheral neuropathy d/t nerve entrapment

Acute treatment of status epilepticus

Phenobarbital, thiopental, phenytoin, benzos, propofol, possibly GA

Treatment for tetanus includes all of the following except: (antitoxin, debridement of the infected area, phenylephrine, intubation)

Phenylephrine

Interscalene Complications

Phrenic nerve paralysis (COPD) Horner's syndrome (Stellate ganglion - C7) Epidural/spinal (needle too medial) Seizures (vertebral artery) C6 neuropathy (intraneural inj) RLN injury (hoarseness) Pneumo (cupola of lung higher on R) Hypotensive bradycardia episode(Bezold Jarish reflex d/t sitting position)

Relative Contraindications to Caudal blocks

Pilonidal cyst abnormal superficial landmarks Hydrocephalus Intracranial tumor Progressive degeneration of neuropathy

Relative contraindications to caudal anesthesia

Pilonidal cyst Abnormal superficial landmarks Hydrocephalus Intracranial tumor Progressive degenerative neuropathy

how do you check the median nerve and what pt. action will you see?

Pinch and Index finger

how do you check the ulnar nerve and what pt. action will you see?

Pinch and fifth digit

Pulmonary complication of RA?

Pleural effusion Restrictive ventilation pattern -Diffuse interstitial fibrosis -Costochondral involvement limits chest wall expansion

Pulmonary complications of RA

Pleural effusion Restrictive ventilatory pattern -Diffuse interstitial fibrosis -Costochondral involvement limits chest wall expansion

What can nitrous oxide cause in patient with TBI?

Pneumocephalus

What is a risk of doing a supraclavicular block?

Pneumothorax from hitting the apex of the lungs

Secondary signs of Parkinson's

Psychosis, depression, dementia, lack of facial expression, diaphragmatic spasm, oculogyric crisis

Which procedures are NOT well suited for an *infraclavicular block*?

Procedures involving SHOULDER or UPPER ARM

Neuraxial recommendations w/ NSAIDs

Proceed w/ neuraxial anesthesia if pt is not on any other blood thinners and has normal clotting mechanisms

Where is CSF produced and reabsorbed

Produced: Choroid plexus Reabsorbed: Arachnoid villi

T12 sensory innervation

Pubic symphysis

In which circumstances is supplemental oxygen LEAST likely to increase arterial oxygenation?

Pulmonary edema

What are (2) examples of instrinsic restrictive lung disease?

Pulmonary edema Aspiration pneumonia Acute Intrinsic= caused by fluid moving into the interstitial space of the pulmonary parenchyma.

Pathophysiology of the PDPH

Punctured dura --> CSF leak from subarachnoid space CSF pressure lost --> cerebral vessels dilate + Brainstem sags into foramen magnum --> stretches meninges, pulls on tentorium

What occurs with extravasation or arterial injection of phenytoin?

Purple glove syndrome Fosphenytoin avoids this risk

Testing branches of the brachial plexus

PusheR, Pull-eM, Pinch ME, Pinch U Radial: Extend arm against resistance Musculocutaneous: Flex arm against resistance Median: Pinch web b/w thumb and index finger Ulner: Pinch pinky finger

What can you use with succs in a patient with myasthenia gravis?

Pyridostigmine- impairs the efficacy of pseudocholinesterase- prolongs duration of succs

The posterior branch of the *femoral n.* innervates the ______________muscles, _____________ joint, and _______________ ligament.

QUADRICEPS (muscles) KNEE (joint) MEDIAL (ligament)

Cutting tip needles

Quincke Pitkin Pros: requires less force Cons: -higher risk of Post dural puncture headache -Less tactile feel -Needle more easily deflected -More likely to injure cauda equina

Cutting tip needle

Quinke Pitkin Requires less force

Which technique is best avoided in the patient with a known difficult airway?

RSI use the predicted difficult airway algorithm

Central nervous system neuraxial analgesia effects

Reduces sensory input to the reticular activating system causes drowsiness

what will you see in a block/lesion to the radial nerve ?

Radial (C5-T1)-*Drop Wrist* - Extensor carpi radialis longus & brevis, Ext. carpi ulnaris. *Difficult to make a fist* Sensory Deficit-Posterior lateral &arm; dorsum of hand index to thumb

This nerve is also derived from the posterior cord. Called "Great Extensor Nerve" because it innervates the extensor muscles of the elbow, wrist and fingers. Sensory innervation is from the skin on the dorsum of the hand on the radial side.

Radial nerve [hand/wrist drop]

What is the anatomic landmark of a *radial n.* at the wrist?

Radial styloid

Acceptable response to twitch monitor (axillary)

Radial: finger or wrist extension Ulnar: ulnar deviation Median: finger flexion Musculocutaneous: bicep twitch

Epinephrine 1:200,000 (5mcg/mL) use does what to LAs?

Reduces vascular uptake of LA and extends block duration

Respiratory effects of neuraxial analgesia

Reduced accessory muscle function Loss of pro perception Apnea results from cerebral hypoperfusion Not result of a phrenic nerve paralysis

Neuroendocrine effects of neuraxial analgesia

Reduces catecholamines, Renin, glucose, thyroid stimulating hormone, growth hormone

Paleocerebellum

Regulates muscle tone -Structure of cerebellum "Paleo diet muscles"

Which devices reduce gas pressure between an oxygen E cylinder and the intermediate pressure system?

Regulator

What does the presynaptic terminal do?

Releases neurotransmitters

Renal complications from RA

Renal insufficiency d/t vasculitis and NSAIDs

What is the 1 PRO of cutting tip spinal needles (Quincke + Pitkin)?

Requires less force

What is the 1 CON of cutting tip spinal needles (Whitacre, Sprotte, Pencan, Greene)?

Requires more force

Most common cause of death with ALS

Respiratory failure

Which peripheral mechanoreceptors are responsible for proprioception and prolonged touch and pressure?

Ruffini's endings

The *posterior femoral cutaneous n.* arises from ______________.

S1 - S3

The posterior femoral cutaneous n. arises from ______________.

S1 - S3

ADULT Dural Sac

S2

INFANT Dural Sac

S3

Sacral hiatus

S5 covered by sacrococcygeal ligament Entry points to epidural space

*Lumbar Plexus* In the Leg

Saphenous n.

Which cells form the myelin sheath in the PNS?

Schwann cells (myelinated beans that get skipped- in periphery)

The _________________ nerve is the biggest nerve in the body.

Sciatic

*Sacral Plexus* Primary Nerves

Sciatic and Posterior Femoral Cutaneous

*Sacral Plexus* In the Leg

Sciatic n. gives rise to: - Common peroneal n. - Tibial n.

What nerve is targeted with a *popliteal block*?

Sciatic n. in the proximal popliteal fossa

C7 sensory innervation

Second and third digits

Misc neuraxial opioids: Sedation is ___ dependent, but most common with _____ Opioids have _______ effect by increasing_______ release Opioid that enters systemic circulation can cross the _______ and enter____ Transfer of opioids from epidural space to _______ is minimal

Sedation is dose dependent, but most common with sufentanil Opioids have antidiuretic effect by increasing vasopressin release Opioid that enters systemic circulation can cross the placenta and enter the fetus Transfer of opioids from epidural space to breast milk is minimal

Status epilepticus

Seizure activity that lasts >30 minutes, or 2 grand mal seizures without regaining consciousness in between

Local anesthetics reduce ________, but proper regional anesthetic does not ___________

Seizure threshold; increase risk of seizures

What causes the BBB to dysfunction

Sites of tumors, injury, infection, or ischemia

Eye complications from RA

Sjogren's sydrome - risk of corneal abrasion

Eye complications of RA

Sjogren's syndrome - risk for corneal abrasion

Key feature of myasthenia gravis

Skeletal muscle weakness that becomes worse later in the day or develops with exercise

From skin to spinal cord

Skin Subcutaneous tissue Supraspinous ligament Interspinous ligament ligamentum flavum (epidural space) dura mater (subdural space) arachnoid mater (subarachnoid space) pia mater spinal cord

Anesthetic mgmt for DMD

TIVA, no succ

Events that cause autonomic hyperreflexia

Stimulation of bladder, bowel, or uterus Bladder catheterization surgery (esp. cystoscopy or colonoscopy) Bowel movement Cutaneous stimulation Childbirth

Is the axillary nerve included in an *axillary block*?

Strangely, no!

Most common culprit responsible for post spinal bacterial meningitis

Streptococcus viridans Found in the mouth, Critical to wear mask

Nervous system complications of SLE

Stroke Psychosis, dementia Peripheral neuropathy

Nervous system complications of SLE

Stroke Psychosis/dementia Peripheral neuropathy

In the adult, new onset seizures are usually the result of...

Structural brain lesion -tumor, head trauma, cerebrovascular event Metabolic cause -hypoglycemia, drug toxicity, withdrawal, or infection

Cause of new onset seizures in adulthood

Structural brain lesion: tumor, head trauma, CVA Metabolic cause: hypoglycemia, drug toxicity, withdrawal, infx

Where does arterial bleeding usually occur in the brain?

Subarachnoid (between arachnoid and pia)

Increased transmural pressure predisposes the aneurysm to rupture- as the vessel bursts where does the blood go?

Subarachnoid space

dural sac

Subarachnoid space terminates In the adults: S2 In the infants: S3

Where does venous bleeding usually occur in the brain?

Subdural space (between dura and arachnoid)

What happens when you accidentally inject LA into the subdural space during an subarachnoid block? What about an epidural?

Subdural space is a potential space between dura and arachnoid mater Spinal dose --> failed spinal Epidural dose --> high spinal w/ delayed onset (15-20 min) (epidural dose into subdural space)

*Hydrophilic* Opioids: Site of action

Substantia gelatinosa Rexed lamina II & III

*Lipophilic* Opioids: Site of action

Substantia gelatinosa Rexed lamina II & III Systemic

Identify substantia gelatinosa on the left side of the spinal cord?

Substantia gelatinosa resides in rexed laminae II and III in the dorsal horn.

What factors increase the risk of contracture in Myotonic Dystrophy

Succ Anticholinesterase reversal Hypothermia (shivering)

Meds to avoid w/ hypokalemic periodic paralysis

Succ Potasium containing solutions (LR)

Meds that are safe with hypokalemic periodic paralysis

Succ??? NDNMB's Acetazolamide

What drugs are safe to administer in the patient with a history of acute intermittent porphyria (2)?

Succinylcholine Nitrous oxide Avoid all barbiturates and etomidate.

Sedation most common with which opioid

Sufentanil

What procedures work best with a *supraclavicular block*?

Supraclavicular block targets trunks/divisions of brachial plexus Best for surgeries AT or BELOW elbow

Patient has remained in ankles crossed position for several hours following induction of anesthesia. Which nerves are at the highest risk of injury? (2)

Sural Superficial peroneal

Consequences of increased intracellular calcium in the myocyte with MH

Sustained muscle contraction-->rigidity Depletion of ATP Increased O2 consumption and CO2/heat production Respiratory (Increased CO2) and lactic acidosis Leakage of potassium and myoglobin into circulation

Autonomic hyperreflexia (dysreflexia)

Sympathectomy above the level of the injury (bradycardia, hypotension) HTN below the level of the injury - further lowers HR d/t baroreceptor reflex 85% of patients w/ injury above T6 will develop AH

What are the CV effects of neuraxial anesthesia? -Sympathectomy causes -Side effects -Treatment

Sympathectomy vasodilates art + ven circulations, but predominantly affects venous capacitance vessels Dec. venous return, CO, BP Volume loading w/ 15mL/kg + vasopressors will minimize HoTN

Autonomic hyperreflexia is unlikely to occur in patients with injury below...

T10

Caudal approach to epidural space is useful for procedures requiring up to:

T10 sensory block (Covers sacral, lumbar, lower thoracic dermatomes)

Up to 85% of patients with an injury above _______ will develop autonomic hyperreflexia

T6 The higher the level of injury, the more intense the response

In 75% of the population, the artery of Adamkiewicz originates between...

T8-T12

Describe train of four monitoring for the patient with hemiparesis?

TOF monitoring on the hemiparetic limb yields a falsely elevated response(meaning false high for relaxation). On the affected side there are extrajunctional receptors at the NMJ as well as on the sarcolema. Decreased sensitivity to Nondepolarizers.

Neuraxial recommendations w/ Thrombolytic agents

TPA, streptokinase, alteplase, urokinase Absolute contraindication to neuraxial anesthesia

Early signs of MH

Tachycardia Tachypnea ↑ EtCO2 Masseter spasm Irregular heart rhythm warm soda lime

Sign of seizure under general anesthesia

Tachycardia, HTN, ↑EtCO2 (d/t ↑O2 consumption)

S/sx of seizures while under GA

Tachycardia, hypertension, increased ETCO2

Early signs of MH

Tachycardia, tachypnea, masseter spasm, warm sodalime, irregular heart rhythm

Examples of Cholinesterase Inhibitors

Tacrine Donepezil (Aricept) Rivastigmine (Exelon) Galantamine (Razadyne)

General presentation of a patient with Marfan's

Tall with pectus excavatum (sunken chest), kyphoscoliosis, and hyperflexible joints (carful with positioning)

What can resemble nerves on an US?

Tendons and ligaments

Myasthenic Crisis vs. Cholinergic Crisis

Tensilon Test: Administer 1-2mg IV edrophonium -if muscle weakness gets worse than its a cholinergic crisis, and the pt should get an anticholinergic -if muscle weakness improves than its myasthenic crisis

Diencephalon contains...

Thalamus and hypothalamus

Diencephalon

Thalamus: acts as a relay station that directs information to different cortical structures Hypothalamus: primary neurohumoral organ

cerebral autoregulation

The ability of the brain to maintain constant cerebral blood flow despite changes in systemic arterial pressure over a range of 50 to 150 mm Hg Benefit: Ensures that the brain has a steady supply of oxygen and substrates in the face of blood pressure fluctuations.

what do a cross-section of peripheral nerves look like?

The characteristic appearance of a peripheral nerve, in ideal ultrasound cross section, looks like a bundle of drinking straws viewed end-on (Honeycomb) -Nerves generally run along borders of other structures especially between different muscle groups.

What is the first landmark for the axial brachial plexus block?

The first landmark to look for is the brachial artery which lies near the surface.

Where do most CNS tumors arise from?

The glia

AXILLARY BRACHIAL PLEXUS BLOCK

The goal is to deposit local anesthetic around the axillary artery. Sometimes, a single injection is sufficient to spread in a "doughnut" shape around the artery. Placing a small amount of local anesthetic solution (3-8 ml) at each nerve location will cause almost immediate anesthesia over their respective areas of innervation. Local anesthetic should also be injected adjacent to the musculocutaneous nerve.

What is the consequence of using more than 5mL volume of LA to block *ulnar n.* at the elbow?

Too much volume = compress ulnar nerve, resulting in ischemic injury

Risks of wake up test

Tracheal extubation Removal of IV & art line access Air embolism Awareness Pain Damage to surgical instrumentation

polyhydraminos should raise suspicion for?

Tracheosophageal Fistula TEF is the letter "T" in the VATER and VACTREL associations

dorsal column-medial lemniscal pathway

Transmits fine touch, proprioception, vibration, and pressure 2-point discrimination = high degree of localizing the stimulus large, myelinated, rapidly conducting fibers transmits sensory information faster than anterolateral system

Anterolateral system - Spinothalamic tract

Transmits pain, temperature, crude touch, tickle, itch, and sexual sensation Smaller, myelinated, slower conducting fibers Transmits sensory information 1/3-2/3 times slower than dorsal column No 2 point discrimination

What is the preferred method for following a nerve along it's course?

Transverse scanning by sliding a broad linear transducer *Transducer manipulation plays a major role in optimizing nerve imaging*

Unacceptable response to nerve stimulator (interscalene)

Trapezius Diaphragm (hiccup)

When should steroids not be given?

Traumatic brain injury

Interspinous ligament

Travels adjacent to And joins the Spinous processes

Posterior longitudinal ligament

Travels on posterior surface of the vertebral body

How can we improve outcomes for out of hospital VF anoxic brain injury patients?

Treatment: mild hypothermia (32-34C) for 12-24 hours -Decreases CMRO2 and can improve outcomes of anoxic brain injury patients

If a patient becomes hypotensive after a hyperbaric spinal, which position do you want to avoid?

Trendelenburg to avoid high spinal

Cranial Nerve V -Nerve name -Function -Bedside test

Trigeminal -VI: ophthalmic -V2: Maxillary -V3: Mandibular Both Somatic sensation to face Somatic sensation to anterior 2/3 tongue Muscles of mastication

What is tic doulureaux? What nerve is affected?

Trigeminal neuralgia CN 5 Excruciating neuropathic pain in the face

Trismus vs Masseter muscle rigidity

Trismus = jaw is tight but can still be opened (normal reaction succ) Masseter = jaw cannot be opened (not corrected by NMB, b/c its an increase in intracellular Ca+) If pt has masseter spasm, assume MH

Trismus vs. masseter spasm

Trismus = tight jaw that can still be opened Masseter muscle rigidity = jaw that cannot be opened

Trismus is a normal response to________ Is it okay to proceed?

Trismus is normal response to succinylcholine Okay to proceed if the trismus occurs in isolation- should consider converting to non triggering agents

Cranial Nerve IV -Nerve name -Function -Bedside test

Trochlear Motor Eye Movement down and center

Femoral Nerve Block Ultrasound Image

VAN

When properly placed the distal tip of the LMA sits at the?

cricopharyngeus muscle (upper esophageal sphincter)

The anterior branch of the *femoral n.* innervates the ______________ surface of the thigh and the ______________ muscle.

VENTRAL (surface) SARTORIUS (muscle)

IV regional anesthesia of the LOWER extremity: Tourniquet inflation pressure if placed on upper leg If the tourniquet is placed on the CALF LA volume Inflation pressure Make sure it does not compress

Upper leg 350-400mmhg; large volume of LA Lower leg/calf LA volume and tourniquet inflation pressure same as upper extremities **Make sure it does not compress peroneal nerve near head of fibula

ALS S/S

Upper neuron: spasticity, hyperreflexia, loss of coordination Lower neuron: muscle weakness, fasciculations, and atrophy Often begins in hands: spreads to tongue, pharynx, larynx, and chest does not affect ocular muscles Orthostatic hypotension, resting tachycardia sensation is intact respiratory failure is most common cause of death

What is the most common comorbidity in children presenting for surgery?

Upper respiratory tract infection

What indices suggest a prerenal cause of oliguria (2)

Urine sodium <20mEq/L Fractional excretion of sodium <1% Decreased RBF causes concentrated urine (increased osmolality and low FE of sodium.

Beir block use and rule of two

Use for foreign body exploration, tendon and joint repair, and repair of lacerations Rule of Two: Two Ivs Two Tourniquets Twenty Minutes Min Two hours max

Late respiratory complications of scoliosis

V/Q mismatching Hypoxemia Hypercarbia (signs of impending failure) Pulmonary hypertension reduced response to hypercapnia Cor pulmonale Cardiorespiratory failure

List the 3 branches of CN V and function

V1: Opthamalic V2: Maxillary V3: Mandibular Somatic sensation to face, Somatic sensation to anterior 2/3 of tongue, muscles of mastication

The sitting position for DBS increases the risk for: If detected the patient should not: What needs to happen if detected?

VAE if VAE detected, pt should not take a deep breath Have surgeon flood field with NS

Late respiratory complications with scoliosis

VQ mismatching Hypoxemia Hypercarbia (sign of impeding failure) Pulmonary HTN, cor pulmonale Reduced response to hypercarbia Cardiorespiratory failure

Infraclavicular block complications:

Vascular puncture- axillary artery and vein are right there Higher incidence of chylothorax Pneumothorax-if needle is too medial *infra has lower incidence of pneumo, stellate ganglion block, phrenic nerve block compared to interscalene and supraclavic

Choose the BEST (2) NMB for the patient with hypertrophic cardiomyopathy?

Vecuronium and Rocuronium (NOT pancuronium it increases HR, not atracurium in releases histamine)

Venous air embolism increases ___ and reduces ___ -What aids in aspiration of entrained air?

Venous air embolism increases dead space and reduces EtCO2 (increased PaCO2 - EtCO2 gradient) -Central line

Cause of ischemic optic neuropathy

Venous congestion in the optic canal reduces perfusion pressure, causing ischemia of the optic nerve Increased intraabdominal and intrathoracic pressure can also increase IOP Ocular perfusion pressure= MAP- Intraocular pressure

Ventral corticospinal tract -What does it innervate? -Where does it cross over?

Ventral corticospinal tract: Fibers that innervate axial muscles remain on the ipsilateral side as they descend this tract -Most cross to the contralateral side when they reach the cervical or upper thoracic area in the spinal cord

Volatile anesthetics cause skeletal muscle relaxation by acting where in the spinal cord?

Ventral horn- so can use gas and potentially eliminate the use of NMB in myasthenia gravis

Where do motor and autonomic neurons exit the spinal cord?

Ventral root

Lateral border of the epidural space

Vertebral pedicles

Which arteries supply the posterior circulation of the brain? Order?

Vertebrals Aorta-->Subclavian a.-->Verterbral a.--> Basilar a.--> Posterior fossa structures and cervical spinal cord

Inverse Steal (Robin Hood, Reverse Steal):

When the patient with an ischemic region of brain is hyperventilated such that PaCO2 falls, blood vessels in non-ischemic brain constrict and blood is diverted to ischemic brain which vessels are already maximally dilated. This theory does not seem to work clinically

Can autonomic hyperreflexia occur postoperativly?

Yes - may present as the effects of anesthesia wear off -Close postoperative monitoring is warranted

Interscalene anatomy 2 [image]

Will only line up like a traffic light is @ about C6

What do you see on the in plane approach?

With this approach, one can see the needle approach the target. However, be aware that it is easy to be a little oblique, and to not actually see the needle tip.

Duschenne Muscular Dystrophy

X-linked recessive disease where cells do not make dystrophin. The lack of dystrophin destabilizes the sarcolemma during muscle contraction and increases membrane permeability. Extracelluar Ca+ enters cells (↑metabolism) Intracellular K+ (cardiac arrest) & myoglobin (renal failure) leave the cell Normal RyR1 receptor

T6 sensory innervation

Xiphoid process

Is an *epidural* safe in the patient w/ MS?

YES

Does US improve success rate?

Yes Brachial plexus block: 99% Popliteal fossa: 89.2% -Around all the nerves is a fascial plane (structure that holds things together). With ultrasound you can see LA/medication go around/cover the fascial plane.

Can you use an epidural for SCI patients?

Yes - however an epidural does not inhibit the sacral nerve roots to the same degree as a spinal anesthetic

Can the recurrent laryngeal nerve be injured with an interscalene block?

Yes, due to large volume of LA -will present as hoarseness

Is hypertension common after an ischemic stroke?

Yes- elevated bp supports CPP/ cerebral O2

Is this a good block to do on a patient with pre existing respiratory insufficiency?

Yes- far enough away from neuraxial and phrenic nerve (diaphragmatic paralysis rarely occurs)

Should levodopa be given morning of surgery?

Yes- prevents worsening of rigidity which can impact ability to ventilate for long procedures- can give it via gastric tube

Do water soluble drugs require a larger dose in neonatal pharmacokinetics?

Yes. They have a larger Vd

Higher risk of post dural puncture headache

Young age Female Pregnancy cutting tip needle Large diameter needle Air for loss of resistance with epidural needle

Factors that cause higher risk of PDPH

Younger age Female Pregnant Cutting tip needle larger diameter needle using air for LOR syringe Needle perpendicular to long axis of meninges

Hypokalemic periodic paralysis is associated with...

a calcium channelopathy

An ischemic CVA most likely stems from...

a cardio-embolic event, such as a-fib

Effects on intacellular volume a) D5LR b) NS c) D5w

a) D5LR - small dehydrated cell b) NS - normal cell c) D5w - swollen bloated cell

Hyperkalemic periodic paralysis is associated with...

a sodium channelopathy

Match each type of peripheral nerve to its function: a) A alpha b) A beta c) A delta d) A gamma

a) A alpha - Motor b) A beta - pressure c) A delta - temperature d) A gamma - muscle tone (muscle spindles)

Match each disease with underlying pathology a) Addisons disease b) Graves disease c) Conns disease d) Hashimotos disease

a) Addisons disease- hypoadrenalism b) Graves disease- hyperthyroidism c) Conns disease- hyperaldosteronism d) Hashimotos disease- hypothyroidism

Match adrenergic receptor to its most potent drug a) Alpha1 bAlpha2 c)Beta1 d) Dopamine1

a) Alpha1- Norepi bAlpha2- Clonidine c)Beta1- Isoproterenol d) Dopamine1- Fendolopam

Match each cardiac pathophysiology with its characteristic pulse waveform? a) Aortic Stenosis - b) Aortic Regurgitation - c) Cardiac Tamponade - d) Systolic left ventricular failure -

a) Aortic Stenosis - Pulsus parvus b) Aortic Regurgitation - Bisferiens pulse c) Cardiac Tamponade - Pulsus paradoxus d) Systolic left ventricular failure - Pulsus alternans

Describe each mode of ventilation: a) Assist control ventilation b) pressure control ventilation c) intermittent mandatory ventilation d) controlled mandatory ventilation

a) Assist control ventilation - spontaneous breaths receive full preset Vt b) pressure control ventilation - tidal volume varies with lung compliance c) intermittent mandatory ventilation - traditional weaning mode d) controlled mandatory ventilation - best used for apneic patients

Match each breathing circuit to the number of valves it has: a) Ayres T-piece- b) Jackson Reece- c) Circle breathing system-

a) Ayres T-piece-0 b) Jackson Reece-1 c) Circle breathing system-3

Match each drug with the enzyme or pathway that it inhibits a) Methylene blue b)Etomidate c) Nitrous oxide d) Tranexamic acid

a) Methylene blue - nitric oxide cycle guanylate monophosphate(inhibits the vasodilatory effects of NO in patients with vasoplegia) b)Etomidate - 11 beta hydroxylase (inhibits steroid synthesis) c) Nitrous oxide - Methionine synthase (inhibits vitamin B12 metabolism and DNA synthesis) d) Tranexamic acid - Plasmin (inhibits fibrinolysis to reduce surgical bleeding)

Match the vasodilator with its primary site of action a) Nitroglycerin: b) Prazosin: c) Nitroprusside:

a) Nitroglycerin: venules b) Prazosin: arterioles c) Nitroprusside: arterioles & venules

Match each twitch to its corresponding nerve: a) Plantar flexion b) Patellar twitch c) Adductor twitch d) Dorsiflexion

a) Plantar flexion- tibial nerve b) Patellar twitch- femoral nerve c) Adductor twitch- obturator nerve d) Dorsiflexion- peroneal nerve

Match each hormone to its primary physiologic effect: a) Secretin b) Motilin c) Cholecytokinin d) Gastrin

a) Secretin- stimulates bile flow b) Motilin- stimulates upper GI motility c) Cholecytokinin- stimulates gallbladder contraction d) Gastrin- stimulates pepsinogen secretion

Match each immunosuppressive drug to its best description: a) Tacrolimus b) Antithymocyte globulin c) Cyclosporine d) Azathioprine

a) Tacrolimus- macrolide antibiotic b) Antithymocyte globulin- polyclonal IgG c) Cyclosporine- 11 aminoacid cyclic peptide d) Azathioprine- prodrug that converts to 6 mercaptopurine

Match each region of the adrenal gland with the primary substance it secretes a) Zona glomerulosa b) Zona fasciculata c) Zona reticularis d) Medulla

a) Zona glomerulosa - releases mineralocoritcoids (aldosterone) b) Zona fasciculata - releases glucocorticoids (cortisol) c) Zona reticularis - releases androgens (dehydroepiandrosterone) d) Medulla - catecholamines (epi and norepi)

Identify region of the myocardium that the lead monitors? a) aVL b) V3 c) II

a) aVL - Lateral LV b) V3 - Anterior LV c) II - RV

Match each event to the laboratory test that is used to monitor it a)Coumadin b) heparin infusion c) fibrinolysis d) aspirin

a)Coumadin - PT b) heparin infusion - ACT c) fibrinolysis - Ddimer d) aspirin - bleeding time

Inhaled agents chemical structures a)Halothane b)Isoflurane c)Desflurane d)Sevoflurane

a)Halothane - the only alkane, 1 Cl-, 1Br, 3Fl b)Isoflurane- 5 Fl, 1 Cl c)Desflurane - 6 Fl d)Sevoflurane - 7Fl

Match each type of WBC with statement that describes it: a)Neutrophil- b)basophil- c)B-lymphocyte- d)T-lymphocyte-

a)Neutrophil- most abundant type of WBC b)basophil- releases histamine c)B-lymphocyte- humoral immunity d)T-lymphocyte- cell mediated immunity

What is the constant in each gas law: a)boyle- b) gay-lussac- c)charles-

a)boyle-temperature b) gay-lussac- volume c)charles-pressure

Identify underlying pathophysiology in each musculoskeletal disease a)duchenne muscular dystrophy b)acute idiopathic polyneuritis c) hyperkalemic periodic paralysis d) myotonic dystrophy

a)duchenne muscular dystrophy - absence of dystrophin b)acute idiopathic polyneuritis - immunologic assault on myelin in the peripheral nerve c) hyperkalemic periodic paralysis - alteration of sodium channels d) myotonic dystrophy - excess calcium availability

Match each complication of TURP syndrome with its presentation: a)fluid overload- b)hypoosmolality- c)glycine toxicity-

a)fluid overload- HTN b)hypoosmolality- SZR c)glycine toxicity- transient blindness

GI hormone site of its secretion: a)gastric inhibitory peptide- b)cholecytokinin- c)secretin- d)gastrin-

a)gastric inhibitory peptide-K cells b)cholecytokinin- I cells c)secretin- S cells d)gastrin- G cells

ASA closed claims: source of M&M and incidence a)respiratory events- b)Regional anesthesia- c)equipment failure- d)cardiovascular events-

a)respiratory events- 17% b)Regional anesthesia- 20% c)equipment failure- 10% d)cardiovascular events- 13%

Following retinal detachment surgery, how long should nitrous oxide be avoided? a)silicone oil b)air bubble c)sulfur hexafluoride

a)silicone oil - 0days b)air bubble- 5days c)sulfur hexafluoride- 10days

Divisions

anterior x 3 posterior x 3

Carbamezapine s/e

aplastic anemia Thrombocytopenia Liver dysfunction Leukopenia ADH like effect - hyponatremia

Larson Maneuver

application of pressure to the laryngospasm notch

Cross-sensitivity to latex is high in patients who are allergic to:

avocado, banana, kiwi, melon, mango, papaya, pineapple, potato, tomato, wheat, figs, chestnut, eggplant

Optic nerve circulation

carotid artery -> ophthalmic artery -> central retinal artery central retinal artery occlusion can lead to blindness

Cerebral Salt Wasting (CSW)

excessive renal wasting of sodium and chloride after brain surgery Brain releases natriuretic peptide and this results in hyponatremia caused by salt wasting in the kidneys

Cauda Equina Syndrome cause

exposure to high concentrations of LA

filum terminale

extends from conus medullaris to the coccyx -continuation of the pia mater caudal to the conus medullaris, anchors spinal cord to coccyx

Pia mater

external covering of the spinal cord, should not be punctured during spinal ansthesia

ventral corticospinal tract

fibers that innervate the axial muscles then descend via the ventral corticospinal tract on the ipsilateral side. fibers crossover to the contralateral side of the spinal cord in the cervical or thoracic region

Classic presentation of PDPH

fronto-occipital h/a -may be accompanied by n/v, photophobia, diplopia, and tinnitus -laying supine relieves h/a

In Eaton-Lambert syndrome, the postsynaptic nicotinic receptor...

is present in normal quantity and functions normally

What are oxybarbiturates?

methohexital phenobarbital secobarbital

White matter

myelinated axons - ascending & descending tracts dorsal, lateral and ventral columns

Primary site of local anesthetic action in spinal anesthesia

myelinated preganglionic fibers of the spinal nerve roots

myotome vs dermatome

myotome = ventral nerves dermatome = dorsal nerves

Secondary signs of AH

nasal stuffiness HTN -> H/A & blurred vision Malignant HTN -> Stroke, seizure, LV failure, dysrhythmias, pulmonary edema, and/or MI

What is the epidural space?

nerve roots, fat pads, blood vessels fat cells act as a lipophilic sink for drugs reducing their bioavailability bupivicaine > lidocaine & fentanyl > morphine

Batson's plexus

network of epidural veins that drain venous blood from the spinal cord and meninges. It passes through the lateral and anterior regions of the epidural space.

What does the grey matter contain?

neuronal cell bodies

Grey matter

neuronal cell bodies in the CNS -processing center for afferent signals from the periphery -H shape of the spinal cord

Cauda equina syndrome

neurotoxicity result of High concentrations of local anesthetics 5% lidocaine and Spinal micro catheters Increased risk Bowel and bladder dysfunction, sensory deficits, weakness, paralysis Supportive treatment

Is there contraindication for succs or NDMAs?

no

Epidural anesthesia has ______ autonomic differential block

no Sensory block 2 - 4 dermatomes higher than motor

Anesthetic mgmt of ALS

no benefit of one technique over another Succ can cause lethal hyperkalemia Sensitivity to nondepolarizing NMB's Bulbar muscle dysfxn increases risk of pulmonary aspiration Chest weakness reduces vital capacity & minute ventilation may need postoperative mechanical ventilation

Nausea/vomiting: neuraxial opioids Caused by activation of what?

opioid receptors in the area of postrema of medulla and vestibular apparatus

Lidocaine onset, anesthesia, and analgesia

onset 10-20 min, anesthesia duration 2-5 hrs, analgesia duration 3-8 hrs

Bupivicaine onset, anesthesia, and analgesia

onset 15-30 min, anesthesia duration 4-8 hrs, analgesia duration 12-18 hrs

Hyperkalemic periodic paralysis is present if skeletal muscle weakness follows...

oral potassium administration (weakness occurs after serum potassium is increased)

Autonomic dysfunction in ALS presents as...

orthostatic hypotension and resting tachycardia

Autonomic dysfunction in Eaton-Lambert syndrome causes...

orthostatic hypotension, slowed gastric motility, and urinary retention

Mannitol

osmotic diuretic dose: 0.25 - 1g/kg MOA: increases serum osmolarity which increases pull of water across the BBB if the BBB is disrupted Mannitol enters the brain and increases cerebral edema causes transient increase in overall blood volume, can stress the failing heart

Injury to a lower motor neuron results in....

paralysis on the same side of the body as the injury

injury to lower motor neurons

paralysis on the same side of the body as the injury presents w/ impaired reflexes and flaccid paralysis Babinski sign is absent

If an injury occurs to a upper motor neuron above the level of decussation (cross over) in the medulla...

paralysis will be on the opposite side of the body

If an injury occurs to a upper motor neuron below the level of decussation (cross over) in the medulla...

paralysis will be on the same side of the body

Hyperbaric solution and supine patient

pool in sacrum and thoracic kyphosis

Caregiver characteristics that increase risk of abuse

poverty, unemployment, lack of education, social isolation, single parent, caregiver is unrelated to the child, hsitory of: substance abuse, mental illness, domestic violence, and neglect during their own childhood

CNS affects of neuraxial anesthesia

reduces sensory input to the reticular activating system. This can cause drowsiness

Nerves most likely to be injured as a result of improper lithotomy positioning

sciatic common peroneal posterior tibial saphenous obturator

What happens with Central Retinal Artery Occlusion? What are the symptoms post anesthesia?

the central retinal artery perfuses entire retina and if it becomes occluded it can cause blindness Sudden painless vision loss in one eye upon emergence- fundoscopic exam reveals cherry red macula and surrounding retina appears pale *note there are several branches of the central retinal artery and you can get a partial visual field defect depending on what is occluded

Bell's palsy results from injury to...

the facial nerve (7) -causes ipsilateral facial paralysis


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