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Intro to regional 2
pathways and drugs
60
Nursing
Graduate
07/29/2009

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Term
Lamina I deals with....
Definition
nociceptive (noxious) stimuli
Term
Lamina II also is known as...
Definition
substantia gelatinosa, MAJOR SITE OF OPOID ACTION
Term
Lamina III and IV deals with...
Definition
non-nociceptive sensory input (epicritic pathways)
Term
Which lamina integrates somatic and visceral input, and is a key player on referred pain?
Definition
Lamina V
Term
alpha delta fibers synapse with which layers of the lamina?
Definition
primarily lamina I and V, lesser with II, III, IV, and X
Term
Which nerve fibers synapse with lamina I and II, and to a lesser extent with V?
Definition
C-fibers
Term
What area of the brain is the major relay station between the second order neurons and the third order neurons?
Definition
the thalamus
Term
Decribe the pathway of pain through the spinothalamic tract
Definition
impulse travels down dorsal root ganglia to dorsal horn, synapse with the 2nd order nerve (or interneuron if reflex arc), 2nd order travels to contralateral side then acends up mylenated fibers that lie anterolaterally, up to the thalamus, thalamus relays it to the somatosensory cortex
Term
name the differences between the lateral STT and the medial STT
Definition
lateral carries discriminative info (laocation, intensity, duration) to the ventral posteriolateral nucleus of the thalamus; the medial STT (also known as the paleospinalthalmic tract)carries autonomic and emotional perception of pain to the medial thalamus
Term
what nerve tract location intervenes with motor function?
Definition
pariaqueductal gray
Term
what are the reticular activation system (RAS) and the hypothalamus responsible for in pain
Definition
the arousal response (wakefulness)
Term
i am a third order neuron, where do i begin and end?
Definition
thalamus to the somatosensory cortex
Term
feet are medial, hands midline, and face/belly/pharynx are lateral on what map?
Definition
sensory homonculus
Term
Glutamate is what?
Definition
primary excitatory CNS neurotransmitter, acts on NMDA receptors, and ketamine antagonizes (sits on the NMDA receptor to reduce pain)
Term
acetylcholine, enkephalins(endorphins), and noreip are all inhibitory neurotransmitters in the CNS, which receptors do they effect?
Definition
acetyl-muscarinic, enkephalins-mu (act like morphine, cause euphoria), norepi- alpha 2 (clonidine and precedex agonize and inhibit pain here)
Term
Which neurotransmitter is the primary inhibitory one?
Definition
gamma amino buteric acid (GABA), also deals with wakefulness (propofol and etomidate enhance this (neurotransmitter)
Term
which neurotransmitter excites mu receptors and is the target of narcs?
Definition
substance P
Term
what is the order of nerve blockade for spinal/epidurals?
Definition
autonomic, temp, pain, touch, pressure, motor, vibration, propriception (ATP TP MVP)
Term
what are the divisions of the spine and numbers of vertebrae?
Definition
cervicle (7), thoracic (12), lumbar (5), sacrum (5), coccyx (4 fused)
Term
which areas of the spine are concave? convex?
Definition
thoracic is concave, convex at the lumbar/cervical
Term
when the pt is supine, what are the highest points of the spine? lowest?
Definition
highest-C5 L5, lowest-T5 S2
Term
kyphosis is...
Definition
exaggerated thoracic curve
Term
lordosis is...
Definition
exaggerated lumbar or cervical curve
Term
scoliosis is...
Definition
abnormal lateral (s) curve
Term
are abnormal curvatures contraindications for SAB or epidurals?
Definition
nope, however they may effect how the drug behaves in the spinal column (level)
Term
name the six components of your vertebral anatomy......and point them out on your partner
Definition
spinous process (spine), lamina, transverse process, superior articular process, pedicle, vertebral foramen
Term
local anesthetics work by...
Definition
binding to the voltage gated Na channel, blocking the influx, inhibiting the propagation of depolarization
Term
what part of the structure of the local anesthetic drug determines how it is classified?
Definition
the linkage chain, which is either an amide or an ester chain
Term
by adding groups and lengthing/shortining the chain of locals, what will happen
Definition
increase/decrease duration, solubility, and potency
Term
are locals mostly acidic or basic?
Definition
weak basic amines
Term
what determines the duration of action in local anesthetics?
Definition
protien binding (why?)
Term
where and how are esters metabolized? what is the derivative?
Definition
in the plasma, hydrolized by plasma cholinesterase, breaks down into PABA
Term
amides are metabolized by.......
Definition
microsomal enzymes in the liver
Term
which ester does not metabolize like the others
Definition
cocaine (metabolized in the liver), metabolites are active
Term
rank these esters in order from metabolized fastest to slowest.....tetracaine, chloroprocaine, procaine, yomomma-aine
Definition
chloroprocaine, procaine, tetracaine
Term
what are most local anesthetic allergies due to?
Definition
ester class production of PABA
Term
what is the shortcut to convert % solution to mg/ml?
Definition
decimal point one place to the right
Term
what is the pKa?
Definition
ph at which 50% of the drug is ionized and 50% is unionized
Term
what does the pKa determine in the action of local anesthetics
Definition
speed of onset
Term
adding bicarb to your local, what will happen?
Definition
speed up the onset due to more unionized drug
Term
if i am basic local with a pKa of 9 and i am injected into opra's gluteus maximus (ph of 7.3), will more of me be ionized or unionized?
Definition
ionized
Term
if i am an acidic local with a pKa of 5.9 and i am injected into the scrotum of ozzy ozborne (ph 2) will more of me be ionized or unionized?
Definition
unionized
Term
what three things should you know when doing pKa problems?
Definition
pKa of drug, if drug is an acid or base, ph of the solution where drug is injected
Term
what form (ionized or unionized) of the local binds to the fast Na channels? What does the other form do?
Definition
ionized binds to the Na channels, unionized crosses membranes
Term
explain ion trapping in the fetus
Definition
fetus ph is lower than mom, unionized drug crosses placenta, in the lower ph the drug becomes more ionized and unable to return to the mom, therfore it is trapped
Term
in which situation would ion trapping be of benefit?
Definition
in the kidney
Term
what is the potency of local anesthetics dependent (mostly) upon?
Definition
lipid solubility
Term
what two properties of the local determines duration
Definition
amount of protein binding (the more binding the longer the action) and lipid soulbility (lipids serve as a storage reservoir, the higher the solubility the longer the duration)
Term
what main characteristic would a local with a high potency and long duration have?
Definition
a high oil:water partition coefficient
Term
how does a vasopressor effect our locals?
Definition
it produces local vasoconstriction, which reduces blood flow, which reduces the amount of drug absorbed into the local capillaries, which prolongs duration of action and reduces chance of toxicity
Term
rank the tissues in order of highest blood flow to lowest
Definition
trach, intercostal muscle, caudal, paracervical, epidural, brachial plexus, subarachnoid/sciatic/femoral, subQ
Term
is risk of toxicity higher in low blood flow areas?
Definition
nope, it is higher in high blood flow areas
Term
what is tissue toxicity of locals usually related to?
Definition
preservatives
Term
what is systemic toxicity of locals related to?
Definition
blood levels secondary to absorbtion from site of injection
Term
what are signs/symptoms of systemic toxicity of locals?
Definition
lightheadedness, tinnitus, seizures, CNS/cardiovascular collapse
Term
what does cocaine do that would cause sympathamometic effects (like HTN, tachy)
Definition
blocks the uptake of norepinepherine
Term
toxic levels of locals.....lidocaine, bupivicaine, tetracaine, chloroprocaine, and cocaine are?
Definition
lido (4mg/kg, 7mg/kg with epi), bup (2.5mg/kg, 3mg/kg with epi), tetra (1.5mg/kg), chloro (9-14mg/kg), coke (3mg/kg)
Term
what do i have to watch for when i am spraying a shitload of cetacaine spray and then my surgeon is going to block with a normal dose of tetracaine?
Definition
toxicity
Term
max dose of epi?
Definition
10mcg/kg in peds, 200-250mcg in adults
Term
should i mix my local with epi if i am going to do a penis block?
Definition
no way man, dont mix epi with locals for blocks in poor circulation areas (penis/fingers/toes) or in IV blocks (beir blocks)
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