BT_RA 1.7 Describe the midline and paramedian approaches to the sub-arachnoid space and epidural space

BT_RA 1.17

Beyond listing the structures you (hopefully) traverse with a spinal needle, it’s not easy to chase down a few facts about this topic without going to the literature, and even that is sparse.

the paramedian approach avoids the ligamentum flavum    T/F

the paramedian approach avoids the interspinous ligament   T/F

the paramedian approach is made more difficult by calcification in the supraspinous ligament   T/F

the first pass success rate of a median approach is greater than that of a paramedian approach in the elderly     T/F

the first pass success rate of a median approach is greater than that of a paramedian approach in younger patients    T/F

SS_PA 1.22 and SS_OB 1.3 Cardiovascular changes at birth


olivia's birth 109


Being born is tough! No wonder newborn infants often have a wizened look to them 😉. Within seconds and minutes of being born huge changes occur to both the cardiovascular and respiratory systems. Some of these changes are irreversible, but the neonate keeps its options open and, for a few days at least, elements of  the cardiovascular system can revert to the foetal status, especially if the baby is under physiological stress.

Tomorrow I will do a post on the respiratory changes at birth, but for today we will stick with the cardiovascular. Most physiology textbooks will cover this topic, Power and Kam’s book gives quite a detailed account, and here is a link to an article in the BJA Education on the topic (be mindful that there is an erratum published – I hope that shows in the link). It is a good idea to revise the foetal circulation before tackling this topic (there is a section on that in the above article)

SS_PA 1.22 Describe the circulatory and respiratory changes that occur at birth

SS_OB 1.3 Describe the transition from foetal to neonatal circulation and the establishment of ventilation


Loss of the placental circulation at birth results in both an increase in the neonate’s systemic vascular resistance and a fall in pulmonary vascular resistance T/F

Neonatal pulmonary vessels have the capacity for hypoxic pulmonary vasoconstriction T/F

The ductus arteriosus closes within minutes of birth, preventing any L to R shunting of blood T/F

Cardiac output in the hours after birth is substantially lower than it is at 8 weeks of age T/F

A newborn’s cardiac output is sensitive to changes in heart rate T/F

A newborn infant will often respond to hypoxia by becoming tachycardic, to improve cardiac output  T/F

Obs, Obs, Baby.

SS_OB 1.6 Describe the changes in the anatomy of the maternal airway and their impact on airway management during anaesthesia.

SS_OB 1.1 Describe the physiological changes and their implications for anaesthesia that occur during pregnancy, labour and delivery.

The increased risk of airway bleeding during manipulation is primarily due to platelet dysfunction in pregnancy. TRUE/FALSE

Lung compliance decreases in pregnancy. TRUE/FALSE

Closing capacity increases during pregnancy. TRUE/FALSE

Oxygen consumption is increased at term, regardless of whether the patient is in labour or not. TRUE/FALSE

Airway oedema can occur due to venous engorgement from labour. TRUE/FALSE

SS_OB 1.7

SS_OB 1.7 Describe the changes in the anatomy of the maternal vertebral column, the spinal cord and meninges relevant to the performance of a central neuraxial block including epidural, spinal and combined spinal-epidural, with appropriate surface markings


TRUE/FALSE  The risk of inadvertent venous puncture, with epidural placement in pregnant women, is the same as in the non-pregnant population

TRUE/FALSE  The line joining the iliac crests (Tuffier’s line) may transverse the body of L5 in late pregnancy

TRUE/FALSE  Epidural space pressure may be positive during labour

TRUE/FALSE  Epidural veins are engorged in late pregnancy

TRUE/FALSE   The ligamentum flavum softens during pregancy

2017.1 : SAQ 1

Previously examined SAQs are a useful study tool. We’ll work through the February 2017 paper for the next couple of weeks.

Question 1 was quite a visual question asking about the anatomy relevant to LIJ line placement.

BT_GS 1.72   BT_RT 1.20

The vagus nerve is in the carotid sheath   TRUE/FALSE

The glossopharyngeal nerve is in the carotid sheath  TRUE/FALSE

Pneumothorax is more likely with LIJ placement than RIJ  TRUE/FALSE

The carotid pulse is lateral to the LIJ  TRUE/FALSE

The LIJ has a greater calibre than the right  TRUE/FALSE

BT_AM 1.1 Describe the anatomy of the upper airway, larynx and trachea, including its innervation and endoscopic appearance

The turbinates project into the nasal cavity from the nasal septum. TRUE / FALSE

When a curved laryngoscope blade is placed in the vallecula, it elevates the epiglottis by tensing the hyoepiglottic ligament. TRUE / FALSE

In an adult, cricoid pressure blocks the oesophagus by compressing it against the C3 vertebral body. TRUE / FALSE

The sensory innervation of the area just above the vocal cords is from the external branch of the superior laryngeal nerve. TRUE / FALSE

The surface landmark that corresponds with the carina is the manubriosternal joint (angle of Louis). TRUE / FALSE

BT_PM 1.1 Anatomy of sensory pathways

I had a Bier’s block for my recent operation – old fashioned, very effective and not examinable in the primary exam😉. I’ve already asked some statements related to local anaesthetics and nerve conduction, so today some statements related to pain pathways.

BT_PM 1.1 Describe the anatomy of the sensory pathways with particular reference to pain sensation

The spinothalamic tracts are in the dorsal column TRUE/FALSE

Primary afferent neurons synapse in the dorsal root ganglion TRUE/FALSE

C-fibres synapse in the substantia gelatinosa TRUE/FALSE

Pain and temperature fibres decussate at the level of the medulla TRUE/FALSE

C-fibres are unmyelinated TRUE/FALSE

SS_PA 1.1 Paediatric Airway Anatomy

Oops, looks like we haven’t had any anatomy for a while.

SS_PA 1.1 Describe the anatomy of the neonatal airway, how this changes with growth and development and the implications for airway management

TRUE/FALSE Under extension of the neck may cause airway obstruction in the neonate

TRUE/FALSE Over extension of the neck may cause airway obstruction in the neonate

TRUE/FALSE Infants are obligate nasal breathers

TRUE/FALSE Neonates have a large tongue in comparison to the oropharynx

TRUE/FALSE Infants are unable to breathe via the mouth

Airway Anatomy IT_AM 1.1

After I intubated my first patient yesterday, blood started coming up the endotracheal tube. On bronchoscopy there was granulomatous tissue extending down the entire trachea… Which inspired me to post an airway anatomy LO.

IT_AM 1.1 Describe the basic structural anatomy of the upper airway including the larynx

TRUE/FALSE The cricoid is the only complete cartilaginous ring in the tracheobronchial tree

TRUE/FALSE The vocal cord is formed by the superior edge of the cricothyroid membrane

TRUE/FALSE The recurrent laryngeal nerve supplies all the intrinsic muscles of the larynx

TRUE/FALSE The superior laryngeal nerve is purely sensory

TRUE/FALSE The posterior cricoarytenoids are the only muscles that open the glottis

The patient had a grade III larynx on DL. The ENT surgeon suggested the granulation tissue might have been related to the use of a bougie when the patient was intubated a month or so ago. Perhaps the rigid plastic bougies are more traumatic than we realise.