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181 Cards in this Set
- Front
- Back
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introduced "nerve block" cocaine into mandible
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halsted
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injected cocaine sol'n b/w spinous processes of inf. dorsal vert. into interspinous lig.
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corning
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invented subarachnoid injection
invented 1st subarachnoid tap |
bier
quinke |
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introduced caudal (epidural) anes
procaine synth in germany |
cathelin
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introduced "controlling" level (hyperbaric) procaine in sab
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barker
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described midline lumbar epidural space approach (segmental epidural anes)
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pages
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added epi to sab to prolong anes
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puckett
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sc descends caudally from _______ to _______ and includes _______ vertebrae: _______, _______, _______, _______, _______
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foramen magnum to sacral hiatus
cervical-7, thoracic-12, lumbar-5, sacral-5(fused), coccygeal-4(fused) |
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_______ vert is largest for weight bearing
its facet joints allow _______ & _______ |
lumbar
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its facet allows rotational movement and the lateral processes of vert are long, heavy, and articulate w/ribs
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thoracic
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triangle shaped section of fused bodies of vert; wedged b/w 2 iliac crests
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sacrum
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_______ is the laminae of last sacral vert that is incomplete & bridged by ligaments
inj point for caudal anes |
sacral hiatus
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_______ is 4 small bone segments fused into 2 bones as individual; triangular shape
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coccyx
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coccygeal projections of articular processes
_______ is most pronounced |
cornua
superior |
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joint angulation is most pronounced in the _______ area
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thoracic
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_______ is formed d/t non-fusion of S5 vertebral arch, cephalad to coccyx
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sacral hiatus
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sacral hiatus is an extension of _______ and covered by _______
site for _______ anes |
ligamentum flavum
sacrococcygeal ligament caudal (epidural) |
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_______ & _______ curve anterior (highest points: _______ & _______)
_______ & _______ curve posterior (low points _______ & _______) |
cervical & lumbar (C5 & L2)
thoracic & sacral (T5 & S2) |
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kids' sc ends @ _______, then ascends to _______ by 18mths
best placement for sab _______ |
L3; L1-L2
L2-S2 (best to start @L3-L4) |
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iliac crest is located @ _______
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L4
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vertebrae are stacked to provide support for _______ & _______ and protection for _______
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cranium & trunk
sc enclosed w/in arch |
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_______ space out vert bodies and cushion the sc
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fibrocartilagenous discs
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_______ & _______ link vertebrae
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articular capsules & ligaments
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KNOW!!!
_______: heavier portion of vert that is congiuous w/_______ |
anterior placed body
pedicles |
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KNOW!!!
pedicles stretch posteriorly to join _______ & _______ to complete posterior arch |
transverse process & spinous process
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KNOW!!!
name parts of vertebrae (except C1) |
ant. vert body, 2 pedicles, 2 trans. processes, laminae, 4 facet joints, 1 spinous process, vert foramen
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KNOW!!!
_______ articulate w/vert above and below (allow motion in the spine) |
facet joints
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KNOW!!!
_______ is arch through which sc travels; smaller in _______, larger in _______ & _______ areas |
vert foramen
thoracic cervical & lumbar |
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_______ has no vert body
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C1
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facet joints are aka _______ or _______ joints
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zygapophyseal or apophyseal
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on each vert, _______ joint faces upward and _______ faces downward, with 1 joint on each side (? & ?)
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superior articular facet
inferior articular facet (R & L) |
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_______: strong fibrous cord connecting tips of spinous processes from sacrum to C7 (and continues upward to _______ as _______); max thick in _______ area
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supraspinous ligament (1st to meet needle)
external occipital protuberance as nuchal ligament |
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_______: think membranous lig, runs b/w spinous processes & blends ant w/_______
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interspinous ligament
ligamentum flavum |
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_______: strongest post lig, connects _______
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ligamentum flavum (LF)
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yellow tough lig that runs from ant/inf vert laminae to post/sup;
most dense in _______ area; final barrier before sc |
ligamentum flavum (LF)
lumbar |
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_______: ant and post lig that run from base of skull to sacrum; attach _______ & _______
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longitudinal ligaments
intervert discs & vert bodies |
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_______: potential space surrounding spinal meninges;
extends _______ to _______; covered by _______ |
epidural space
foramen magnum to sacral hiatus sacrococcygeal lig boundaries |
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name the sacrococcygeal lig boundaries
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anterior: post longtitudinal lig
lateral: pedicles & intervert foramina posterior: LF & ant surface of lamina |
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epidural space contains _______, _______, _______, & _______
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nerve roots
fat lymphatics arteries |
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_______ provide drainage of blood from sc and cord lining
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internal vert venous plexus
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LF is _______ in the middle and _______ towards sides of sc
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thicker
thinner |
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sc starts in foramen magnum of _______ & _______ and ends below _______
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brainstem & medulla oblongata
conus medullaris |
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at birth sc ends @ _______ and moves _______ to reach adult position @ _______ by _______ age
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L3
cephalad L2 2yrs |
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spinal nerve are attached to sc by 2 roots: _______ & _______
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anterior (motor) &
posterior (sensory) |
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_______: portion of sc that gives rise to rootlets of single spinal nerve
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cord segment
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_______: skin area innervated by given spinal nerve and its cord segment
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dermatome
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sc is protected by _______ & 3 conn. tissue coverings called _______ (_______, _______, & _______)
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vert column & meninges (dura, arachnoid, & pia mater)
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_______: tough outermost mem covering spinal column
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dura mater
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_______: firmly attached to foramen magnum of occipital bone, and
_______: dural sac ends @ S2 |
sup dura mater
inf dura mater |
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inf dura mater is pierced by _______ (an extension of _______)
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filum terminale
pia mater |
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_______: extends from sc to blend w/periosteum on post coccyx
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filum terminale
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dura becomes _______ upon reaching intervert foramina and continues as _______ of periph nerves
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thinner
perineural conn tissue |
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_______: middle meningeal layer; closely conn to dura and ends @_______
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arachnoid mater
S2 |
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_______: potential space b/w dura and arachnoid; may explain fx spinals, high epidurals
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subdural space
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_______: delicate vascular membrane that contacts outer surface of sc
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pia mater
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_____: space bw arachnoid & pia mater, filled w/CSF;
continous w/central canal of cord & ventricles; site for SAB |
subarachnoid space (SAS)
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3 divisions of SAS
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cranial (surrounds brain)
spinal (surrounds sc) root (surrounds dorsal & ventral roots) |
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spinal nerve roots transverse _____ and carry meningeal layers w/_____, _____, _____, & _____ spaces
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epidural space
epidural, subdural, subarachnoid, & subpial |
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as dura extends toward intervert foramen it becomes _____
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thinner
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_____: ultrafiltrate of bld plasma in osmotic & hydrostatic equilibrium that runs b/w _____ & _____
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CSF
pia & arachnoid mater |
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most of CSF is formed in ...
_____ml made each day and absorbed via _____ |
choroid plexus in lateral, 3rd, & 4th ventricles
450ml subarachnoid villi into adj venous sinus |
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~_____ml CSF in SAS
Flows through _____ to _____ into _____ Bathes _____, _____, & _____ |
25-35ml
ventricles-->foramen of luschka & magendie-->SAS sc, cauda equina, & brain |
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CSF is 90% _____, also _____ & _____
pH=_____ sp grav=_____ |
H2O; 'lytes & glucose
7.39-7.50 1.003-1.009 (isobaric) |
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CSF+dextrose=_____
CSF+H2O=_____ CSF+plain LA=_____ |
hyperbaric
hypobaric isobaric |
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specific gravity increases w/_____, _____, & _____ and decreases w/_____
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age, hyperglycemia, hypothermia
hyperthermia |
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CSF maintains _____ & _____ for CNS
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physiologically stable env & buffering capacity
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majority of CSF in sc in _____ (horizontal position pressure=_____)
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lower cauda equina
(6-8cm H2O) |
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arterial supply enters via _____ of SC, aorta, and iliac arteries
enters _____, crosses _____, enters _____ in region of _____ |
radicular branches
intervert foramina epidural space SAS dural cuff of spinal nerve roots |
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2 paired PSAs arise from _____ and descend _____; fed by _____ and send vessels to _____
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inf cerebellar a.
medial to post nerve roots 25-40 radicular a. post white & gray columns |
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_____: formed at terminal part of each vertebral a.
runs down midline ant and sends branches into _____ & _____ |
ant spinal a.
center of sc & into ant & lat gray and white columns |
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how does LA get into sc?
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CSF & LA enter Virchow-Robbins space and enter sc
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1 ASA supplies _____
2 PSA supply _____ |
ant 2/3 sc
post 1/3 sc |
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three longitudinal vessels are fed by spinal branches of the following arteries... (6)
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vertebral
deep cervical ascending cervical post intercostal lumbar lat sacral |
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75% of motor tracts in sc supplied by...
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1 ASA
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upper sc receives blood from _____, middle from _____, and lower from _____
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branches of sc a.
branches of intercostal & lumbar a. (T3 & T4) branches of internal iliac a. |
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radicular a. give rise to 3 branches...
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ant & post a.
neuromedullary a. a. of adamkiewicz (radicularis magna) |
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ant & post a. supply...
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vert column
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neuromedullary a. supplies _____ & _____ via...
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sc & meninges
ant & post radicular a. |
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_____ is the largest feeder of sc; ant segmented medullary a. that supplies ASA mainly in lumbar enlargement; enters b/w T8 & L3
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a. of adamkiewicz (radicularis magna)
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most tenuous region of bld supply is _____ d/t sluggish flow
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T4 (tenuous supply to ant sc!)
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high thoracic and cervical sc supplied mainly by branches of _____
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subclavian a.
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ischemia in ant sc mainly results in _____
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motor deficits
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extensive sx manipulation of ant sc can result in _____, causing _____, _____, &/or _____
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ischemia of conus medullaris
ischemia, motor deficit, +/or paralysis |
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stimulation of sns cz _____, _____, & _____
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vasoconstriction, sweating, bowel constriction
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pre-gang nerves of sns originate in _____ and pass through _____
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lat gray column of gray matter
spinal nerves from T1 to L2 |
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_____ are motor, sensory, and symp fibers that exit vert column thru intervert foramina
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spinal nerves
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spinal nerve and corresponding cord segment are named for
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intervert foramen thru which they run
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sns pre-ganglionics leave spinal n. to become part of _____, go up/down symp chain, and synapse at/above/below point of entry
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white rami comunicantes
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_____ runs alongside sns pre-ganglionics on the anterolateral surface of vert column
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symp paravert ganglia
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_____ & _____ innervate the gut
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celiac ganglia &
mesenteric ganglia |
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symp post-gangl fibers innervate _____, _____, _____, & _____
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bld vessels (constr), heart (incr chronotropy & inotropy), bronchi (dilation), smooth muscle (bladder contr & bowel distention)
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psns pre-gangl fibers reside in _____ & _____ and synapse w/short post-gangl fibers in _____
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cranial n. & S2-S4
walls of organs they innervate (i.e. vagus n.-GIT motility & tone, sacral n.-bladder and lower GIT) |
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SAB and epidural used for _____, _____ & _____ procedures (not higher d/t _____)
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lower abd, extremity, limited upper abd
(don't want anes of lungs) |
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indications for neuraxial RA (=spinal, epidural, caudal)
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lower abd, gyne/ob, hernia, lower limb, uro, perineal, rectal
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benefits of RA
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no GA risk of 'full stomach'
no airway/intub difficulties (but should still prep for it!) |
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sx stress results in metabolic/endocrine elevations in..
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prolactin
growth h. ACTH, ADH (vaso) cortisol, aldo, renin catecholamines bld glucose |
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stress response (=hormonal changes) d/t sx can be modulated with _____ or _____
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high epidural or spinal anes (although inconsistently effective in upper abd sx)
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SAB+epi (vs. GA)=less bld loss
total hip repl=_____ prostatectomy=_____ TURP=_____ hysterectomy=_____ c-section=_____ |
22-50%
37% 18% 45% ?% |
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why is there less bld loss when SAB+epi used?
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hypotension (no sns response) &
redistribution of bld flow away from op site (steal effect) |
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SAB/epidural effect on thromboembolic phenomena
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sns blockade=incr bld flow and decr venostasis in LE; also decr stress response-->decr platelet aggregation; also higher plasminogen-activator levels = :-) DVT/PE outcome
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CAD benefits of RA (and why?)
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<pre/afterload in pts w/CHF, aortic/mitral regurg d/t sns blockade and arteriovasodilation
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CAD detriments of RA (and why?)
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mitral/aortic stenosis, cardiomyopathy b/c pre/afterload decr may be critical
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absolute contraindications for epidural/spinal
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pt refusal; allergy to LA
shock/severe hypovolemia uncorrected coags sepsis @ LP site abnormal anatomy elevated ICP |
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relative contraindications for epidural/spinal
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deformity/tattoo
pre-existing dx of sc chronic HA/backache no success w/in 3 attempts aortic stenosis |
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pts w/post-op epidurals have better outcomes such as...
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lower mortality, reduced cost, less infections, earlier extubation
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what is the precaution for pts w/hx of mobitz I or II or 3rd block w/o pacemaker?
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Large vol LA may stabilize cardiac cellular membrane and increase heart block
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_____: level of skin that corresponds to respective sensory innervation by spinal nerves
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dermatomes
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_____ & _____ mediate visceral sensation and visceromatic reflexes and help determine segmental levels of anes for op
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cutaneous n. distribution & autonomic afferents from organs
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sensory dermatomes include _____, _____, _____, & _____
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cervical 1-8
thoracic 1-12 lumbar 1-5 sacral 1-5 |
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sensory dermatomes:
_____ clavicle, _____ nipple _____ diaphragm, xiphoid _____ pelvis, sym pubis |
T2, T4
T6 T10 T12-L1 |
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_____ ilioing lig, heel, 5th toe
_____ genitofem n. _____ med ankle _____ big toe, _____ knee |
L1
L1-2 L4 L5, S2 |
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KNOW!!!
LA into CSF provides total blockade _____ and anesthesia _____ to site of injection |
blockade - caudad
anesthesia - cephalad |
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absolute contraindications for epidural/spinal
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pt refusal; allergy to LA
shock/severe hypovolemia uncorrected coags sepsis @ LP site abnormal anatomy elevated ICP |
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relative contraindications for epidural/spinal
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deformity/tattoo
pre-existing dx of sc chronic HA/backache no success w/in 3 attempts aortic stenosis |
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pts w/post-op epidurals have better outcomes such as...
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lower mortality, reduced cost, less infections, earlier extubation
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what is the precaution for pts w/hx of mobitz I or II or 3rd block w/o pacemaker?
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Large vol LA may stabilize cardiac cellular membrane and increase heart block
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_____: level of skin that corresponds to respective sensory innervation by spinal nerves
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dermatomes
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_____ & _____ mediate visceral sensation and visceromatic reflexes and help determine segmental levels of anes for op
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cutaneous n. distribution & autonomic afferents from organs
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sensory dermatomes include _____, _____, _____, & _____
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cervical 1-8
thoracic 1-12 lumbar 1-5 sacral 1-5 |
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sensory dermatomes:
_____ clavicle, _____ nipple _____ diaphragm, xiphoid _____ pelvis, sym pubis |
T2, T4
T6 T10 T12-L1 |
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_____ ilioing lig, heel, 5th toe
_____ genitofem n. _____ med ankle _____ big toe, _____ knee |
L1
L1-2 L4 L5, S2 |
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KNOW!!!
LA into CSF provides total blockade _____ and anesthesia _____ to site of injection |
blockade - caudad
anesthesia - cephalad |
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KNOW!!!
level of cephalad anes depends on _____, _____, & _____ |
pt position
total dose LA baricity of LA sol'n |
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KNOW!!!
blockade of sns fibers extends _____ than sensory fibers |
2-4 segments higher
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KNOW!!!
_____ fibers are most difficult to block |
motor (Aalpha & Abeta)
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KNOW!!!
motor fibers block _____ than sensory blocks |
2 segments
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KNOW!!!
block onset is _____ > _____ fibers > _____ fibers |
sns > sensory > motor
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_____ fibers are most sensitive to LA
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pregang sym fibers (B-fibers)
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_____ fibers are blocked 1st and remain blocked longest
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pain C-fibers (sensation to cold)
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_____ fibers are blocked and recover 2nd
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A-delta fibers (pin-prick)
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_____ fibers are last to block and 1st to recover
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A-beta fibers (touch)
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_____ fibers are the largest, and less sensitive to LA than sensory fibers
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A-alpha (motor)
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level of motor block is _____ dermatomes _____ than sensory anesthesia
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2-4 dermatomes
lower than |
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_____ or _____ anes good for perineal/vag sx; blocks _____ dermatomes
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low spinal or saddle block
sacral |
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T10 spinal anes useful for which procedures?
T4 or T6? |
TURP, cystoscopy, lower extremity sx
intra-abd sx, c-section (T4) |
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_____: weight in gm of 1ml sol'n @ specific temp (usually gm/ml)
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density
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_____: ratio of density of sol'n compared to water @ same temp
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specific gravity
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_____: ratio of density of LA to density of CSF at same temp
CSF density @37C=_____ |
baricity
1.003g/ml |
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density of baric sol'ns varies inversely w/_____
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temp
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isobaric sol'n baricity ranges _____ to _____
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0.9998 to 1.0008
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in a supine pt, hyperbaric sol'n results in a rise of anes to _____ level
in sitting pt for 5min it cz _____ |
T5
saddle block |
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less important factors for LA behavior in SAS
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site/level/speed of inj, physical status/age, intra-abd pressure, direction of bevel
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duration of blocks:
_____: short-acting _____: intermed-acting _____ & _____: long-acting |
procaine (short)
lidocaine (med) tetracaine & bupivacaine (long) |
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_____ spinals are most popular and achieve higher level of SAB; prepared commercially by adding _____.
|
hyperbaric
glucose |
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hyperbaric sol'n spreads _____ in sitting position and _____ in trendelenberg position
|
caudad
cephalad |
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_____ is long-acting drug for SAB
mixed w/D10=_____ mixed w/sterile H2O=_____ duration:_____ |
tetracaine
hyperbaric hypobaric 2-3hrs (longer w/Epi) |
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FDA rec for Lidocaine dilution
|
Lido5% + D7.5% (hyperbaric)
Lido2% (isobaric) can be used if preservative-free |
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Hyperbaric bupivacaine contains _____ and is _____-acting w/_____ onset than tetracaine
Isobaric bupi is _____% |
Bupivacaine0.75% + D8.25%
shorter-acting, slower onset 0.5% |
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_____: alpha2-agonist that cz decr bld flow and analgesia w/short and intermed LA
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epinephrine
|
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_____ ug/ml Epi added to SAB prolongs block duration _____%
|
5
40-70% |
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_____: alpha2-agonist that inhibits C & A fibers when given with LA
|
clonidine
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clonidine prolongs sensory block ~100min when _____ug added to long-acting LA for _____, _____, & _____ blocks
|
100-150ug
neuraxial, IV, periph n. |
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larger doses of clonidine (>150ug) w/long-acting LA cz _____, _____, & _____
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hypotension, sedation, bradycardia
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procaine prep is _____%
duration=_____min duration w/epi=_____min |
10%
45min 60min |
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bupivacaine prep is _____
duration=_____min duration w/epi=_____min |
0.75% in D8.25%
90-120min 100-150min |
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tetracaine prep is _____
duration=_____min duration w/epi=_____min |
1% in D10%
90-120min 120-240min |
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lidocaine prep is _____
duration=_____min duration w/epi=_____min |
5% in D7.5%
60-75min 60-90min |
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ropivacaine prep is _____
duration=_____min duration w/epi=_____min |
0.2 to 1%
90-120min 90-120min |
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dose for procaine for
peri,lower,saddle=_____ lower abd T10=_____ upper abd T2-T4=_____ |
75mg
125mg 200mg |
|
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dose for bupivacaine for
peri,lower,saddle=_____ lower abd T10=_____ upper abd T2-T4=_____ |
4-10mg
12-14mg 12-18mg |
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dose for tetracaine for
peri,lower,saddle=_____ lower abd T10=_____ upper abd T2-T4=_____ |
4-8mg
10-12mg 10-16mg |
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dose for lidocaine for
peri,lower,saddle=_____ lower abd T10=_____ upper abd T2-T4=_____ |
25-50mg
50-75mg 75-100mg |
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dose for ropivacaine for
peri,lower,saddle=_____ lower abd T10=_____ upper abd T2-T4=_____ |
8-12mg
8-12mg 16-18mg |
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procaine:
dose range:_____mg 2-derm regression:_____min resolution:_____min prolonged by adr. agonists:_____% |
50-200mg
30-50min 90-120min 30-50% |
|
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chloroprocaine:
dose range:_____mg 2-derm regression:_____min resolution:_____min prolonged by adr. agonists:_____% |
30-100mg
30-50min 70-150min N/A |
|
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lidocaine:
dose range:_____mg 2-derm regression:_____min resolution:_____min prolonged by adr. agonists:_____% |
25-100mg
40-100min 140-240min 20-50% |
|
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bupivacaine:
dose range:_____mg 2-derm regression:_____min resolution:_____min prolonged by adr. agonists:_____% |
5-20mg
90-140min 240-380min 20-50% |
|
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tetracaine:
dose range:_____mg 2-derm regression:_____min resolution:_____min prolonged by adr. agonists:_____% |
5-20mg
90-140min 240-380min 50-100% |
|
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two chief landmarks for SAB and epidural
|
iliac crests identify L4 spine or L4-L5 interspace
spinous processes identify midline |
|
|
sc ends at _____, so safe SAB choices are _____, _____, _____, or _____
|
L1-2
L2-3, L3-4, L4-5, L5-S1 |
|
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most popular position for SAB is _____
|
lat decubitus (opens up interspaces; max flexion of knees & hips, shoulders & iliac crest inline)
|
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easier to find midline in obese pts in _____ position, but disadvantages are
|
sitting position
vasovagal/fainting, discomfort for hip fx pt |
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in the midline approach for SAB the bevel should be parallel to the dural fiber b/c...
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reduces extent of dural tear and incidence of post-dural h/a by splitting rather than cutting fibers
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in midline approach for SAB in lumbar region needle should be angled _____ and when it enters _____ you may feel a pop
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slightly cephalad
ligamentum flavum |
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gold standards for SAB include _____, _____, & _____
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free flow of CSF
no heme no parasthesia (although common & transient) |
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if you hit bone on SAB approach...
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redirect needle cephalad, walk up lamina
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if parasthesia is present...
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NEVER inject!
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a 22g introducer over a 25g or 26g needle prevents...
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spinal needle bending and contact w/prep sol'n
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describe the paramedian approach for SAB (useful esp. in _____ pts)
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arthritic
insert needle 1cm lat to edge of sp. process, direct toward same midline entry point |
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describe the taylor approach for SAB
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more extreme paramedian angle
approached @ L5-S1 (largest vert. interspace) |
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level of anes must be documented at _____, _____, & _____ in PAR
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1min, 5min, end of sx
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