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1

depolarizes such as sux's is 2 molecules acting like ACh at the post synaptic receptor and is characterized by two phases! what occure in phase 1

-decreased single twith
-No fade (decrease but sustained response) to continuous stimuli
-TOF ratio greater than 0.7
-potentiation by anti-cholinesterase drugs
-causes fasculations

2

depolarizes such as sux's is 2 molecules acting like ACh at the post synaptic receptor and is characterized by two phases! what occure in phase 2

resembles non-depolarizers characteristics
-decreased twitch to a single stimulus
-produce FADE (unsustained response) to continual stimulus
-TOF ratio < 0.7
-post tetanic facilitations

3

Non-depolarizeres act on at least 1 alpha subunit to block conduction what are their characteristics

-decreased twitch to a single stimulus
-produce FADE (unsustained response) to continual stimulus
-TOF ratio < 0.7
-post tetanic facilitations
-potentiation by other non-depolarizers
-antagonism by anticholinesterase drugs

4

why do we relax muscles

-for optimal intubation conditions
-facilitate surgical exposure/manipulation
-improve mechanical ventilation
-to compensate for inadequate or light anesthesia

5

what is teh purpose of nerve monitoring

to evaluate the degree of muscle paralysis or recovery from paralysis

6

Hz for a single twitch

0.1-0.15 Hz one time

7

how does TOF work with nerve monitoring

2Hz 0.5 sec apart

8

what do the twitches look like
if you could see them in the form a a line (real practical)
single
TOF
TOF with fade

single
_________

TOF
__________
__________
__________
__________

TOF with fade
__________
________
______
____

(i know looks just like real life real easy to invision)

9

Non-depolarizers fade 2 characteristics

--exhibit FADE on TOF
--the fade may progress to no twitches if enough NDMR is given
ex::
| I __________ FIRST DOSE
| N ________
| C ______
| R ____
| E
| A
| S ________ CONT'D DOSING
| I ______
| N ____
| G __
|
| N
| D ____ ANOTHER DOSE
| M __
| R
|
| D
| O __ WHAT THE HELL MORE
| S
| E
| NONE AHHH GONE
V

10

************************************must know
How do you know the degree of block with TOF
use
R1
R2
R3
R4
R=response to nerve monioring with TOF
questions see slide 45

R4--decreaes at 75% receptors blocked
R3--decreaes at 85% receptors blocked
R2--decreaes at 90% receptors blocked
R1--decreaes at 95% receptors blocked
ex::: with TOF
R1 __________
R2 __________
R3 ________
R4 ______

so this shows the first decrease was at R3 so that indicates this individual hypothetical made up patient is 85% blocked!!!!
so just remember if you are checking to see is someone is blocked and you do TOF and only the very last twitch is slightly faded your still at least 75% block thats still alot!!!

11

clinical application to nerve monitoring %
-surgical relaxation is appretiated at
-intubation facilitated at what
-total flaccidity

-surgical relaxation is appretiated at >90%
-intubation facilitated at 95%
-total flaccidity at 99%

12

Examples of TOF with depolarizing blockade (SUXs) TOF
baseline TOF
__________
__________
__________
__________

baseline TOF
__________
__________
__________
__________

Phase 1
_____
_____
_____
_____

(notice no fade, but all are at about half strength of baseline) (called 4/4 TOF with less amplitude)

Phase 2



(no I didn't forget any lines thats it, when depolarizers go into phase 2 usually there are no twitches)
recorded as 0/4

13

quick reveiw
-do NDMR have fade?
-Depolarizes have 2 phases describe their TOF

-do NDMR have fade?
--yes
-Depolarizes have 2 phases describe their TOF
-phase 1-seen as TOF 4/4 with less amplitude
-phase 2 seen as TOF 0/4 NO TWITCHES

way to go if your correct pat yourself on the back!! if your wrong kick yourself in the nuts for not paying attention and do it again dumbass

14

3 most frequently used musles for nerve monitoring

no specific order
1) ulnar-adductor pollicis
2) facial- Currigator Supercilii
3) posterior tibial- flexor hallucis

15

this was not in our notes but from all of the pictures and a CRNA I asked what lead goes where for nerve monitoring (Red and Black)

black -distal
red closest to heart.
just an fYI dont memorize

16

where are the leads for the adductor pollicis (hmm where is that muscle) and what should you see to show proper twitch eval

ulnar (palmar) side of distal forearm.
the thumb should show adduction
hmm lets find a hint:
ok so we are testing the ADDUCTOR pollicis and the proper eval is ADDUCTION of the thumb!!!!!!! skadush (sir wizard Atkins, J., 2012) ( I have to give credit to the Skaduch)

17

what would be seen in the adductor pollicis twitch if the placement of the leads are wrong for example on the median nerve or direct muscle

finger contraction

18

what is the facial nerve we access for with twitch

Curragator Supercillii
(in his notes he places emphisis on NOT THE ORBICULARIS OCULI)
HOW TO REMEMBER- this is a streatch so if you have a better one place let me know- Curragator= Cornea
superCILLII= Cilli (hairy projections) your eyebrow????

19

Facial nerves efferent or afferent

primarily efferent (motor control)

20

the facial nerve is cranial nere number???

XII

21

**5 branches of the cranial nerve

temporal
zygomatic
maxillary
mandibular
buccal

22

where is placement of nerve leads for posterial tibial nerve (flexor Hallucis) monitoring

behind the medial malleolus

23

stimulation of the posterior tibial nerve (flexor hallucis) causes what response

flexion of the big toe by contraction of the flexor hallucis

24

what is teh nerve we monitor in the posterior tibia

flexor hallucis

25

which nerve is best to monitor??? and why

the corrugator supercilli (face) is relatively resistant to blockade and very similar to diaphragm resistance
so monitor the facial nerve for intubation and abd rectus paralysis
-the ulnar (adductus pollicis) is very easliy blocked so monitor for extubation adequacy
hint:
go to sleep and stay asleep with eyes closed, and wake up with thumbs up!!!

26

again to ensure you grasped it's importance when do you monitor the face and ulnar nerve

go to sleep and stay asleep with eyes closed, and wake up with thumbs up!!!

27

**************************************************
name the % of receptors occupied (you need to know this)
Normal TV
Holds tetanus 50Hz
Equal TOF, DBS
Holds tetnas 100Hz
Head lift x 5 secs

Normal TV--0-80% may be blocked
Holds tetanus 50Hz--0-75%or80% may be blocked
Equal TOF, DBS--0-75% or 80% may be blocked
Holds tetnas 100Hz--0-50% may be blocked
Head lift x 5 secs--0-33% may be blocked

just remember these are UP TO amounts a very wide range.

28

What is single twicth monitoring for

allows continual eval of DEPOLARIZING block

29

what is TOF for

allows est of DEGREE on NON-DEPOLARIZERS

30

what is DBS for

easier visual eval of fade, give same info as TOF