Regional & Pain 00 / 32 , all cards and bookmarks
The governing rule 01 / 32 Block the nerves that supply the operation; spare what this patient cannot afford to lose.
Shoulder surgery: what to cover Neuraxial level by operation What this patient cannot afford to lose Report a problem with card 1: The governing rule
The anticoagulant clock 02 / 32 Count hours since the last dose; anti-Xa helps only under 24 hours; fibrinogen after thrombolysis.
Wait from the last dose to needle or catheter removal Drug and dose Minimum wait Therapeutic enoxaparin, 1 mg/kg twice daily → , open its explanation At least 24 hours Prophylactic enoxaparin → , open its explanation 12 hours Subcutaneous (SC) heparin 5000 units two or three times daily → , open its explanation 4–6 hours, or normal coagulation SC heparin 7,500–10,000 units twice daily → , open its explanation 12 hours, then confirm normal coagulation Therapeutic rivaroxaban for atrial fibrillation → , open its explanation Stop 3 days before an epidural steroid injection
Therapeutic low-molecular-weight heparin (LMWH) inside 24 hours Catheter event Report a problem with card 2: The anticoagulant clock
The pain rule 03 / 32 Name the pain by mechanism, then treat the mechanism: drugs, injection, stimulation; opioids last.
Pain First move Post‑herpetic or diabetic neuropathic pain → , open its explanation Amitriptyline, serotonin‑noradrenaline reuptake inhibitor (SNRI) or gabapentinoid; not opioids or blocks Fibromyalgia pain → , open its explanation Cognitive behavioural therapy, not massage or acupuncture Complex regional pain syndrome of the arm → , open its explanation Stellate ganglion block: diagnostic, eases physiotherapy Mechanical low back pain, no radiculopathy → , open its explanation No imaging; reassure, stay active, conservative management
Report a problem with card 3: The pain rule
When regional beats general 04 / 32 Regional wins when it monitors, protects or avoids what general anaesthesia cannot.
Which block: head, neck, shoulder and chest 05 / 32 Choose the block whose nerves cover the incision.
Block by operation Operation Block Skin surgery: lateral neck, earlobe, mandibular angle → , open its explanation Superficial cervical plexus block Rotator cuff repair, shoulder → , open its explanation Interscalene brachial plexus block Shoulder surgery with significant lung disease → , open its explanation Suprascapular plus axillary block; no interscalene or supraclavicular Awake carotid endarterectomy → , open its explanation Superficial cervical plexus block Cleft lip or palate repair, infant → , open its explanation Infraorbital (maxillary division), not supraorbital; palate: maxillary block if experienced Thoracotomy → , open its explanation Thoracic epidural or continuous paravertebral catheter; never lumbar
Complication of a deep cervical block Report a problem with card 5: Which block: head, neck, shoulder and chest
Which block: abdomen, pelvis and leg 06 / 32 Choose the block whose nerves cover the incision or stop the reflex.
Block by operation Operation Block Inguinal hernia repair, neuraxial refused → , open its explanation Transversus abdominis plane (TAP) block, or ilioinguinal–iliohypogastric block where offered Lower abdominal surgery, neuraxial refused → , open its explanation Add TAP block to general anaesthesia Great toe amputation → , open its explanation Deep peroneal, superficial peroneal, posterior tibial, saphenous blocks Great or second toe amputation, proximal approach → , open its explanation Popliteal sciatic plus saphenous block covers everything Ankle or foot surgery analgesia → , open its explanation Popliteal sciatic block, plus saphenous if needed
Reflex during surgery Report a problem with card 6: Which block: abdomen, pelvis and leg
Caudal volume 07 / 32 Dose the caudal per kilogram by the level the surgery needs.
Opioid tolerance: continue, add, rotate 08 / 32 Never drop the baseline opioid; to rotate, choose methadone and start below the calculated dose.
Patient-controlled analgesia (PCA) 09 / 32 PCA is demand-only: no routine background; fix poor analgesia by the demand dose or lockout.
The analgesic plan and its doses 10 / 32 Anchor on a local anaesthetic technique, then pick the systemic drug and dose for the setting.
Back, neck and facial pain: the next step 11 / 32 Image for red flags or a secondary cause; inject after conservative care, non-particulate in the neck.
Neuropathic pain, fibromyalgia and complex regional pain syndrome (CRPS): first-line treatment 12 / 32 Start with non-opioid drugs or behavioural therapy; opioids and procedures come later.
Neuropathic pain Pain First-line treatment Post‑herpetic neuralgia → , open its explanation Amitriptyline; not opioids, NSAIDs or nerve blocks Painful diabetic neuropathy with allodynia, hyperalgesia → , open its explanation Amitriptyline, SNRI or gabapentinoid Neuropathic back pain, diabetes, previous stroke → , open its explanation Tight glucose control first; paracetamol is not neuropathic Ordinary, non‑neuropathic back pain after stroke → , open its explanation Paracetamol is first‑line; avoid COX‑2 inhibitors after stroke
Fibromyalgia Complex regional pain syndrome Report a problem with card 12: Neuropathic pain, fibromyalgia and complex regional pain syndrome (CRPS): first-line treatment
Sympathetic blocks and neuromodulation 13 / 32 Block or stimulate the pathway that carries the pain.
Naming the nerve from the deficit 17 / 32 Map the numb skin or weak muscle to one nerve before blaming the block.
Naming the pain 18 / 32 Name it by trigger, distribution and the history behind it.
Pain terms Pain syndromes Presentation Name Many tender sites ≥3 months, normal investigations → , open its explanation Fibromyalgia syndrome Hand pain, swelling, poor function after fixed fracture → , open its explanation Complex regional pain syndrome Seconds‑long shocks in one trigeminal division → , open its explanation Trigeminal neuralgia Painful one‑sided dermatomal vesicles, older age → , open its explanation Herpes zoster: reactivated latent varicella, not new infection Low back pain worse standing and extension → , open its explanation Facet arthropathy; confirm with medial branch blocks
Complex regional pain syndrome: the two types Report a problem with card 18: Naming the pain
Local anaesthetic systemic toxicity (LAST) 19 / 32 Suspect LAST after any large dose; lipid early, benzodiazepine for seizures, small-dose adrenaline.
Finding after a block Finding after a block What it is Agitation, tinnitus, fainting, hypotension after epidural bolus → , open its explanation LAST, not total spinal or high block Caudal bupivacaine above weight‑based maximum, then collapse → , open its explanation LAST; anaesthetised children show cardiac signs first Circumoral numbness, metallic taste, tinnitus, dizziness → , open its explanation Early central nervous system (CNS) signs of LAST; circumoral numbness first (Barash)
Treatment Observation afterwards Report a problem with card 19: Local anaesthetic systemic toxicity (LAST)
The block went too high 20 / 32 Apnoea or collapse without excitation after a block is high block; tinnitus or agitation means LAST.
Hypotension and bradycardia after a block 21 / 32 Hypotension with bradycardia after a block: name the reflex or additive; ephedrine, adrenaline if severe.
Naming the cause Finding Cause Interscalene, upright: sudden hypotension, bradycardia, unresponsiveness → , open its explanation Bezold–Jarisch reflex Profound bradycardia, collapse after spinal with hypovolaemia → , open its explanation Bezold–Jarisch reflex, a proposed mechanism Spinal adjunct adding hypotension, sedation, possibly bradycardia → , open its explanation Alpha‑2 agonist such as clonidine, not an opioid
Hypotension after spinal Report a problem with card 21: Hypotension and bradycardia after a block
Side effects after a neuraxial block or opioid 22 / 32 Sympathetic spread and opioid itch are expected; restlessness with a full abdomen is retention.
Finding after the block What it is Drooping eyelid, small pupil, one side, during epidural → , open its explanation Benign Horner from sympathetic spread; reassure, keep catheter Itch after intrathecal morphine → , open its explanation Opioid action in dorsal horn (substantia gelatinosa), not histamine Restlessness with lower abdominal fullness after spinal → , open its explanation Urinary retention; examine the bladder first Oral herpes simplex flare after neuraxial opioid → , open its explanation Triggered by morphine, not local anaesthetic
Report a problem with card 22: Side effects after a neuraxial block or opioid
Complications of named blocks 24 / 32 Each block's complications come from its target's effects, its neighbours, or territory it misses.
Toxicity other than LAST 25 / 32 Treat the toxin: naloxone for opioid, methylene blue for methaemoglobin.
Landmarks and planes 29 / 32 Each block has one plane or bony landmark; find it before injecting.
The autonomic nervous system 30 / 32 Sympathetic outflow is thoracolumbar; block it at the ganglion.
Pain pathways and nerve fibres 31 / 32 Small fibres carry pain to the dorsal horn, which modulates it; unrelieved pain harms organs.
Traps Check these before you finish 1 card · about 1 min 32 Traps
Traps 32 / 32 The tempting call is the familiar one: the usual block, drug, number, position or diagnosis.
Tempting Right call Rapid injection causing high spinal block → , open its explanation Head‑down tilt with flexed hips spreads hyperbaric drug; rate inconsistent Total spinal after epidural or caudal bolus → , open its explanation Agitation, tinnitus, dizziness: LAST from intravascular spread Allodynia for mild heat on burn → , open its explanation Primary hyperalgesia per Faust; allodynia per Barash Femoral nerve causing the thigh jerk → , open its explanation Obturator nerve: adduction during lateral bladder wall resection Remove epidural catheter for Horner signs → , open its explanation Reassure, continue epidural: harmless sympathetic spread Lateral femoral cutaneous nerve in adductor canal → , open its explanation Saphenous nerve; lateral femoral cutaneous is not in canal C6‑C7 transforaminal betamethasone → , open its explanation Non‑particulate dexamethasone only; no particulate steroid 12 hours after therapeutic enoxaparin → , open its explanation 24 hours after 1 mg/kg twice daily; 12 prophylactic Hypotension as first sign in infants → , open its explanation Apnoea or desaturation first: high or total spinal Blood patch for non‑postural migraine‑like headache → , open its explanation Migraine: treat with a triptan, not a blood patch Early electromyography (EMG) after block nerve deficit → , open its explanation Nerve conduction studies now; EMG after 1–4 weeks Temperature fibres blocked first → , open its explanation Sympathetic B fibres first; temperature first among sensory
Report a problem with card 32: Traps
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Sheet 02 · Regional & Pain 32 / 32
That is Regional & Pain, all 32 cards.
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Part 1 · Decisions What to do
04 · When regional beats general Regional wins when it monitors, protects or avoids what general anaesthesia cannot. 05 · Which block: head, neck, shoulder and chest Choose the block whose nerves cover the incision. 06 · Which block: abdomen, pelvis and leg Choose the block whose nerves cover the incision or stop the reflex. 07 · Caudal volume Dose the caudal per kilogram by the level the surgery needs. 08 · Opioid tolerance: continue, add, rotate Never drop the baseline opioid; to rotate, choose methadone and start below the calculated dose. 09 · Patient-controlled analgesia (PCA) PCA is demand-only: no routine background; fix poor analgesia by the demand dose or lockout. 10 · The analgesic plan and its doses Anchor on a local anaesthetic technique, then pick the systemic drug and dose for the setting. 11 · Back, neck and facial pain: the next step Image for red flags or a secondary cause; inject after conservative care, non-particulate in the neck. 12 · Neuropathic pain, fibromyalgia and complex regional pain syndrome (CRPS): first-line treatment Start with non-opioid drugs or behavioural therapy; opioids and procedures come later. 13 · Sympathetic blocks and neuromodulation Block or stimulate the pathway that carries the pain.