What are the layers the needle passes through for a spinal anesthetic?
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A laboring pt receives an epidural, dosed with UH's mix of Marcaine/epi/fentanyl. The pt complains of difficulty breathing and is unable to squeeze her hand when asked. What is your concern?•High spinal •Level higher than C5 blocking motor innervation of the diaphragmMotor innervation of diaphragmphrenic nerve (C3-C5)What will you do?-for high spinal•Stop any epidural infusion •Tilt pt in reverse trendelenberg(may not help, but doesn't hurt) •Call for help •Administer supplemental O2 •Be prepared to PPV (ambu bag-mask) and go to OR for stat C-section •Will likely need cardiovascular support (d/t high sympathectomy and reduced cardiac accelerator fiber activity) •If need to intubate (remember, full stomach!), need to administer sedative/hypnotic -pt is still completely awake!What are the two components of an epidural test dose? (drug, volume and concentration)•3mL of 1.5% lidocaine and 1:200k epi •45mg lidocaine •15mcg epinephrineWhat is an epidural test dose used to rule out?•Intrathecal catheter placement -lidocaine would cause spinal block •Intravascular catheter placement -epinephrine would cause inc.HR/BPAn epidural catheter is inadvertently placed in the intrathecal space and dosed with 20mL 2% lidocaine. The ptimmediately loses consciousness. Why and what will you do?•Total spinal l•Call for help! •Secure airway •Support hemodynamics •This ptIS unconscious (as opposed to pt with HIGH spinal), so amnestics aren't necessary at this pointAmnesticsUsed in combination with analgesics to produce "twilight sleep" and depress memory formationAn epidural catheter is inadvertently placed intravenously. 10mL 0.75% Marcaine is injected, and the pt instantly goes into vfib and loses pulses. Why and what do you do?•LAST •Call for help! •Secure airway, start CPR •Call for intralipid (Bolus 1.5mL/kg, gtt @ 0.25mL/kg/min •Low dose (< 1mcg/kg) epi bolus as indicatedWhat types of innervation does a spinal/epidural block and in what order?(i.e. what is the easiest to block, what is the most resistant to block?)•First to block -autonomic (sympathetic) •Sensory •Hardest to block -motorIf your pthas a T6 sensory-block level after a spinal anesthetic was administered, what level would you expect their motor block to be?T8 •Sympathetic -sensory -motor each occur about 2 levels apart from each otherWhere would you expect their sensory level to be 2 hours after the spinal was placed?T8 to T10 •Drops 1-2 levels per hourThe specific gravity of the local anesthetic relative to the CSF is referred to as its _?_BaricityThe dermatome associated with the umbilicus is what level?T10The dermatome associated with the xiphoid process is what level?T6The dermatome associated with the pinky finger process is what level?C8The only cutting-type spinal needle we use is called a _?_ needleQuinckeTuffier'sline connected the SPICs denotes what vertebral level?L4A lidocaine spinal anesthetic with the pt positioned in lithotomy results in increased risk of what painful condition?Transient neurological symptomsYou're placing an epidural, get loss of resistance, disengage your LOR syringe, and warm fluid drips out of the needle without stopping. What happened?Dural puncture / wet tapWhat symptoms is this pt likely to exhibit 24 hours later?-dura puncturePost dural puncture headacheWhat are some treatment options for this patient?-Post dural puncture headache-supine -lights off -hydration -Nsaids/tylenol -caffeine -opioids -epidural blood patchHow many centimeters long is a standard Tuohy needle?11.5cmHow many cm of catheter do we typically place in the epidural space?4-6cmAn epidural is performed and LOR is achieved at 6cm. The catheter is advanced into the epidural space and the Tuohy needle is removed. At what cm marking should you secure the catheter to the pt's back in order to leave 5cm of catheter in the epidural space?•11cm @ skin •6cm "skin to space" + 5cm catheter in epidural spaceYou place a lumbar epidural for a laboring patient. After a negative test dose, you inject 10mL of the MEF solution. 5 minutes later, the pt has a BL T10 level to pin prick. She complains of nausea and says she thinks she's going to vomit. What's the first thing you should do?Bolus phenylephrine/ephedrineBasal skull fracture is a contraindication to what type of emergency airway technique?•Blind nasal intubation •Also nasal trumpet placement •(also NGTs)-nasogastric tubesYou have a view of the vocal cords during a glidescope intubation, but you are unable to get the ETT through the glottic opening. What device can you use to intubate the trachea, then act as an exchange catheter for the ETT placement?Gum elastic bougieThe McGrath blade is a video scope on what shaped blade?Mac-style curved bladeWhat position should the patient be in for an RSI?Back up / reverse trendelenburgWhat is Sellick's maneuver?"cricoid pressure"When should cricoid pressure be removed after RSI intubation?After ETT placement confirmation-officially etCO2 x 3-5 breathsWhat is the name of the oral airway specifically used to aid oral FOB?OvassapianWhat cranial nerve are the recurrent and superior laryngeal nerves branches of?Vagus(CN X)Of the superior laryngeal nerve, which branch supplies motor, which sensory, between the epiglottis and vocal cords?•Sensory-internal •Motor-externalWhat's the name of the endotracheal tube commonly used with FOB, designed to not get caught on the arytenoids/VCs?Parker tubeAn overdamped arterial line waveform will __ estimate the systolic and __ estimate the diastolic pressureUnder-estimate the systolic and over-estimate the diastolicA modified Allen's test is to assess for adequate collateral circulation from the __ arteryulnarPlacing a needle into a vessel, passing a wire through the needle, removing the needle, threading a catheter over the wire, and removing the wire ... is also known as what technique?Seldinger techniqueThe dicrotic notch / incisura is due to what?•Incisura -aortic valve closure •Dicrotic notch -... just say aortic valve closure -But really, due to the reflected wave from peripheral arteriolesThe further away the arterial catheter is placed from the aortic valve, the __ the systolic pressure and the __ the diastolic pressure reported by the waveform•Higher SBP •Lower DBPWhat's the term used to describe tingling or numbness from pressure on a nerve?ParesthesiaWhich electrolyte abnormalities would you expect to see during a MTP in which 10u PRBC, 10u FFP, 15pk platelets, and 1L 5% albumin had been given using 0.9% normal saline as the carrier fluid?•Hyperkalemia •Hypocalcemia •HypernatremiaWhat is the treatment for hyperkalemia?•Insulin/dextrose •Albuterol •Calcium chloride/gluconate •Hyperventilation •Sodium bicarbonate •Kayexalatevon Willebrand factor (vWF)Assist platelets to adhere to the collagen fibersWhat coagulation factors are in cryoprecipitate that are not found (in high concentration) in FFP?•Fibrinogen (factor I) •Factor VIII •Factor XIII •vWFWhat are the vitamin K dependent coagulation factors?Factors II, VII, IX, XWhat factors are found in 3 factor prothrombin complex concentrate (PCC; KCentra)? In 4 factor PCC?•II, IX, X •II, VII, IX, XWhat 4 factors does Warfarin inhibit?II, VII, IX, XHow much is 1u PRBC expected to raise the Hgb g/dL? Hct?•1g/dL •3%Why are blood transfusion not given with LR as the carrier fluid?•Sodium citrate binds calcium (anticoagulating the stored blood) •LR contains Ca++ •Giving transfusions with LR will precipitate thrombiWhat are the three aspects of the lethal triad with exsanguination and MTP?•Hypothermia •Metabolic acidosis •CoagulopathyExsanguinationLoss of blood to the point where life can no longer be sustained.central venous pressure waveformwaves: a, c, v trough/descents: x, y a-atrial contraction c-tricuspid bulging during early ventricular systole v-venous return against closed TV x-atrial relaxation, downward displacement during mid-ventricular systole y-tricuspid valve openingCVP derangements-loss of A waveatrial fibrillation(no atrial contraction)CVP derangements-Fusion of C and V waves/or just less of an X-descent, and rapid Y-descentTricuspid RegurgitationCVP derangements-Cannon A wave3rd degree heart block or Vtach/PVCs -Caused by atrium contracting against closed tricuspid valve (bc ventricular systole is occurring simultaneously)Central line placement -steps1.Prep neck (possibly scan first) -put pt head down 2.Scrub, gown, glove 3.Prep kit 4.US probe cover on -scan neck 5. Needle/angiocath on syringe -aspirate as you go 6.Vein is accessed -remove syringe 7.Insert wire -beware ectopy 8.Needle/angiocath out -rescan to see wire in vessel 9.Scalpel incision (lateral aspect of wire) 10.Dilator in, out 11.CVC over wire 12.Wire out 13.Aspirate and flush all lines -suture in place 14.CXREctopymalposition; displacementPulmonary artery catheter placement -steps1.Place PAC through "swandom" 2.Connect ports to pressure tubing and transducers 3.Advance catheter through sheath introducer(Balloon up @ 15cm) 4.First pressure seen will be: CVP ~ 5 mmHg -nickel 5.Next pressure seen will be: RV ~ 25/0 mmHg -quarter 6.Next pressure seen will be: PAP ~25/10 mmHg -quarter/dime 7.Next pressure seen will be: PCWP ~10 mmHg -dimeColor coded PAC lumens:•Blue: CVP •Yellow: PAP •White: VIP •Red: pilot balloonMAC linecordis catheter(PSI)The 3-neuron afferent pain pathway consists of nerves synapsing in what 3 locations?•Dorsal root ganglion •Dorsal horn •Contralateral thalamusWhat tract is AKA the major pain pathway?Anterior lateral spinothalamicWhat two types of nerve fibers transmit pain?•A-delta fibers •C fibersWhat's the term used to describe a painful response to a non-painful stimulus?AllodyniaWhat's the term used to describe tingling or numbness from pressure on a nerve?ParesthesiaWhat's the term used to describe repeated nociceptive stimuli resulting increasing excitability even after the stimulus is removed, leading to chronic pain?Central sensitization / wind-upWhat preventative measure do we take to minimize the risk of intravascular local anesthetic injection during PNB?Aspirate before injectionOn an ultrasound image, is liquid hyperechoic or hypoechoic?HypoechoicWhat's the term used to describe local anesthetic injected by the surgeon to anesthetize terminal cutaneous nerves?Field blockWhat's the toxic dose of lidocaine with and without epinephrine?•4.5mg/kg without •7mg/kg withHow many mL of 0.5% Marcaine can a 60kg pt receive?30MLMarcaine dose2.5mg/kgWhat are some symptoms of local anesthetic toxicity that might precede seizure and cardiovascular collapse?•Tinnitus •Blurred vision •Circumoral numbness •Metallic taste in mouth •AgitationWhat medication can be added to lidocaine to speed its onset?Sodium bicarbonateWhat is the only local anesthetic which vasoconstricts?cocaineHow are amide LAs metabolized?hepatic metabolismHow are ester LAs metabolized?PseudocholinesterasesA pt receives an interscalene nerve block for a shoulder procedure. The PACU RN alerts you that she's concerned the pt had a stroke bc of facial drooping on the same side as the surgery. What confounding syndrome makes the diagnosis complicated?Horner's syndromeMrs. Puffer is a 35-year-old single mother, just getting off the night shift. She reports to the ED in the early morning with shortness of breath. She has cyanosis of the lips. She has had a productive cough for 2 weeks. Her temperature is 102.2, blood pressure 110/76, heart rate 108, respirations 32, rapid and shallow. Breath sounds are diminished in both bases, with coarse rhonchi in the upper lobes. Chest X-ray indicates bilateral pneumonia. •ABG results are: •pH= 7.44 •PaCO2= 28 •HCO3= 22 •PaO2= 54Acid base -compensated respiratory alkalosis Oxygenation: 54mmHg is < 60 -hypoxic Expected PAO2 = 0.21(713)-28/0.8 = 115Bill Ding is a placing an IV in preop in an otherwise healthy 17yo female pt. After he misses 4 IVs, she appears very anxious and says that her heart is racing. Bill is successful on his next attempt, but it turns out that he placed the IV into her radial artery. He decides to make the most of it and sends an ABG. •ABG results are: •pH= 7.49 •PaCO2= 24 •HCO3= 23 •PaO2= 105•Acid base -uncompensated respiratory alkalosis •Oxygenation -appropriateSihamis admitted to the ED with SOB and a history of smoking 2ppd since she was 12. She's put on 3L/m NC and an ABG is sent. •ABG results are: •pH= 7.3 •PaCO2= 63 •HCO3= 29 •PaO2= 68•Acid base -respiratory acidosis with partial metabolic compensation •Oxygenation -bad •Expected PAO2= .32(713)-63/0.8 = 150mmHg •A-a gradient = 82A-a gradient normal rangeAn 89-year-old Caleb presents with fever, rigors, hypotension and reduced urine output. He appears confused and is unable to provide any meaningful history. The care home that the patient came from has provided some basic documentation. You look through the information available and note that the nurse changed Caleb's catheter 24 hours ago. The hospitalist orders antibiotics, aggressive fluid resuscitation and asks you to perform an arterial blood gas, with the results shown below. Caleb was not on oxygen at the time of the ABG. •ABG results are: •pH= 7.29 •PaCO2= 41 •HCO3= 15 •PaO2= 93•Acid base -uncompensated metabolic acidosis •Oxygenation -fine (80-100mmHg) •Na 149, Cl 108, CO2 16 ➔calculate the anion gap and ID as HAGMA or NAGMA 149-108-16 = 25 ➔HAGMA -likely urosepsis (high uremia/lactic acidosis)normal bicarbonate levels22-26 mEq/LMyles was admitted to the hospital 10 days ago with a fractured neck of femur. The orthopedic team repaired the fracture and he has been an inpatient on the orthopedic ward recovering ever since. Myle's nurse is becoming increasingly concerned as the Myle's oxygen requirements are increasing (he is now on 3L) and he is now tachypneic (respiratory rate 35). In addition, he has recently started complaining of calf pain. •ABG results are: •pH= 7.51 •PaCO2= 23 •HCO3= 21 •PaO2= 45•Acid base -respiratory alkalosis with partial metabolic compensation •Oxygenation -hypoxic •Cause -DVT ➔PEPulmonary Embolism TreatmentAnticoagulation therapy is initiated -heparin is the anticoagulant of choice. -Low-molecular-weight heparin or warfarin is continued after the acute phase.Warfarin (Coumadin)Anticoagulant, Vitamin K AntagonistVitamin K antagonistwork by inhibiting the action of vitamin K