Ranalli Exam 2 Study Hub: ENT + Geriatrics + Acute/Chronic Pain

Built for select-2, matching/dropdown, sequence/order, hot spot anatomy, and those sneaky “all/none of the above” vibes. Emphasis: Ranalli-made tables, review-session pearls, NBCRNA-style high yield.

Acute Pain

Must-know pain terms

  • Algesia = increased sensitivity to pain
  • Algogenic = pain-producing substance/stimulus
  • Allodynia = non-harmful stimulus perceived as painful
  • Dysesthesia = unpleasant abnormal sensation
  • Hyperalgesia = heightened response to painful stimulus
  • Neuralgia = pain in distribution of peripheral nerve
  • Neuropathy = abnormal nerve function
  • Paresthesia = abnormal sensation, usually tingling/pins/needles

4 pain processes

  • Transduction: noxious stimulus → action potential at nociceptor; targets: local anesthetic/corticosteroid/NSAID
  • Transmission: peripheral → dorsal horn → ascending tracts; targets: local anesthetic, neuraxial/regional, TCAs/steroids
  • Perception: thalamus/cortex emotional + sensory experience; targets: opioids, TCA/SNRI, α2 agonists, GA, NMDA antagonists
  • Modulation: descending inhibitory pathways; targets: NMDA antagonists, opioids, α2 agonists, NSAIDs

Fibers + mediators

  • A-delta = myelinated, fast, sharp, localized first pain
  • C fibers = unmyelinated, slow, dull/burning/aching second pain
  • Substance P = C fiber, slow/chronic pain, NK-1 receptor
  • Glutamate = A-delta + C fibers, AMPA/NMDA, rapid excitatory transmission
  • Bradykinin = strongly algesic inflammatory mediator
  • Histamine = edema/vasodilation, released from mast cells/basophils/platelets

Acute pain physiology consequences

  • ↑ sympathetic tone → tachycardia, HTN, ↑ myocardial demand
  • Splinting/shallow breaths → atelectasis, hypoxemia, pneumonia risk
  • ↑ stress response/cortisol/catecholamines; hyperglycemia
  • Reduced mobility → DVT/PE risk; poor cough and pulmonary toilet

Preventive/multimodal analgesia

  • Goal: attenuate nociceptive input before/during/after surgical insult to reduce peripheral + central sensitization
  • Common multimodal: local anesthetic/regional, acetaminophen, NSAID if safe, low-dose ketamine, dexmedetomidine, lidocaine infusion in selected abdominal surgery
  • Chronic pain patient: continue baseline pain meds when appropriate, expect tolerance/hyperalgesia, plan regional/PCA/early pain consult

Serotonin syndrome — Ranalli trap zone

  • Triad: neuromuscular + autonomic + mental status changes
  • Most important Hunter sign = clonus (spontaneous, inducible, ocular); also hyperreflexia
  • Hyperthermia is a big sign; severe cases → rhabdo, renal failure, DIC, ARDS
  • Review note: keep hyperkalemia on the differential/complication radar even if not on the chart
  • Common periop culprits: SSRIs/SNRIs/TCAs/MAOIs + meperidine, tramadol, fentanyl/methadone risk, linezolid, methylene blue
  • STOP: Stop offending agents + Supportive care; Treatment with benzodiazepines; Oxygen/intubation/paralysis/sedation if severe; Pharmacologic antidote cyproheptadine
  • Avoid antipyretics, beta blockers, haloperidol, succinylcholine

Chronic Pain

Definitions + categories

  • Chronic pain = uninterrupted pain >3 months; negative sensory + emotional experience
  • Categories: psychogenic, inflammatory, neuropathic
  • Do not dismiss as psychosomatic: all pain has psychological components, but that does not mean “not real”

Wind-up / central sensitization order

  • Repetitive nociceptive stimulation
  • NMDA activation → ↑ intracellular calcium
  • Release glutamate + substance P; second messenger activation
  • COX activation → prostaglandin synthesis
  • ↓ inhibitory pathways + ↑ excitability
  • Hyperalgesia + allodynia → positive feedback loop

Chronic pain systems

  • Interneuronal: glutamate/NMDA activation and loss of GABA/glycine inhibition
  • Bulbospinal: serotonin/noradrenergic pathway dysfunction
  • Non-neuronal: glial activation → pro-inflammatory mediators

CPSP

  • Chronic postsurgical pain = persistent pain >2 months postop not explained by other causes
  • Risk procedures: thoracotomy, mastectomy, open cholecystectomy, nephrectomy, sternotomy, amputation, hernia repair
  • Prevention: regional anesthesia, preop anti-inflammatory agents, anti-hyperalgesic meds: ketamine, esmolol, lidocaine, dexmedetomidine

CRPS

  • CRPS = persistent regional pain/inflammation beyond initial injury after surgery/trauma/stroke/MI
  • CRPS-1 = no specific nerve injury; majority
  • CRPS-2 = specific nerve damage
  • Symptoms: unprovoked pain, pain after contact, temp/color/swelling changes, stiffness, weakness/movement disorder
  • Treatment is multimodal: NSAID/APAP, anticonvulsants, antidepressants, topical anesthetic, steroids, ketamine infusion, opioids, psychotherapy/rehab/graded motor imagery, SCS/intrathecal pump in select cases

Procedures / devices

  • Radiography reduces intravascular injection risk and helps needle placement; contrast can cause nausea, hypotension, bronchospasm, hives, anaphylaxis; ionic contrast = higher allergy risk; caution ESRD
  • Lumbar epidural: interlaminar = simpler/lower vascular or nerve-root injury risk; transforaminal = targeted but higher technical/vascular risk
  • Local anesthetic = rapid short-term relief/placement confirmation; corticosteroid = delayed longer-term anti-inflammatory effect
  • Steroids: betamethasone/triamcinolone/methylprednisolone particulate; dexamethasone nonparticulate; particulate risk = vascular occlusion if IV
  • Contraindications: refusal, allergy, infection, malignancy, coagulopathy; relative: CHF/uncontrolled DM
  • RFA/cryo: long-term sensory impulse reduction; destroy myelin with axon intact
  • Sympathetic ganglion: diagnostic short-term = local anesthetic; therapeutic long-term = alcohol/phenol/RFA
  • Sphenopalatine = facial/cluster/trigeminal; stellate = UE/thoracic/hyperhidrosis/postherpetic; celiac = abdominal/pancreatic cancer; hypogastric = pelvic pain
  • TENS = nonpainful stimulation competes in dorsal horn; SCS = failed back/CRPS/refractory, dorsal column/gate theory, reversible adjustable; risks lead migration/infection/hematoma/CSF leak

ENT / Otolaryngologic Anesthesia

Hot spot practice: On larynx figures, expect ligament/cartilage/nerve-label style questions. Drill: internal SLN pierces thyrohyoid membrane; cricothyroid membrane is the emergency access landmark; thyroid/cricoid/epiglottis are unpaired.

Mini hot spot: click the cricothyroid membrane

Simplified anterior larynxThyroidCricoidTrachea← cricothyroid membrane

Larynx anatomy — memorize tables

  • Paired cartilages: Arytenoid, Corniculate, Cuneiform
  • Unpaired cartilages: Thyroid, Cricoid, Epiglottis
  • Sensory: internal SLN = above cords; RLN = below cords; glossopharyngeal = superior epiglottis/base of tongue
  • Motor: RLN = all intrinsic muscles except cricothyroid; external SLN = cricothyroid
  • Intrinsic: cricothyroid tenses/elongates; thyroarytenoid/vocalis relax; posterior cricoarytenoid abducts; lateral cricoarytenoid + transverse arytenoid adduct; aryepiglottic/oblique arytenoid close glottis
  • Memory: “PB + LAD” → Posterior cricoarytenoid = aBducts; Lateral cricoarytenoid = ADducts

Extrinsic laryngeal muscles

  • Infrahyoid/depressors: sternohyoid, sternothyroid, thyrohyoid, omohyoid — mostly ansa cervicalis/cervical plexus with thyrohyoid via C1 hypoglossal fibers
  • Suprahyoid/elevators: digastric, stylohyoid, mylohyoid, geniohyoid — aid swallowing/elevate hyoid/larynx
  • Test angle: know “intrinsic moves cords/glottis; extrinsic moves larynx/hyoid as a unit”

Special airway equipment

  • RAE tube = Ring-Adair-Elwyn, not “right angled ETT”; oral RAE points down/south, nasal RAE points up/north
  • Armored/reinforced tubes: flexible and useful at extreme angles, oral or nasal; NOT immune to occlusion/kinking/compression
  • MLT = small ID/long tube for microlaryngeal work; laser tubes for airway laser

ENT principles

  • Shared airway: secure tube extremely well, long circuits/IV tubing, protect pressure points, communicate before turning/draping
  • Avoid sustained NMB when nerve monitoring/isolation required: thyroid/parathyroid/facial nerve procedures; consider NIM tube and short-acting/none after intubation
  • Deliberate hypotension: improves view by decreasing bleeding; goal often MAP ~60 or 20% below baseline; need patient selection, A-line/IV titration; agents include volatile, propofol, remifentanil, nitroglycerin/nitroprusside, beta-blockers, CCBs, dexmedetomidine
  • Avoid/limit N2O in closed spaces: tympanoplasty/middle ear graft, sinus/closed-space concerns

Airway fire / lasers

  • Fire triad: oxidizer + ignition + fuel
  • Prevention: lowest feasible FiO2, avoid N2O, laser-safe tube, saline-filled cuff/methylene blue, wet pledgets, laser signs/eye protection/smoke evacuation
  • If airway fire: stop ventilation/disconnect circuit, stop gases, remove ETT, extinguish with saline/water, re-establish airway, bronchoscopy, assess injury, reintubate if needed
  • Laser characteristics: precision, minimal bleeding; CO2 common; delayed healing is NOT a classic advantage

ENT procedures / complications

  • Thyroidectomy: continue antithyroid meds, consider NIM tube, avoid deep extubation, assess PACU hypocalcemia/hematoma/RLN injury
  • Unilateral RLN injury = hoarseness; bilateral = stridor/respiratory distress/aphonia risk
  • Expanding neck hematoma = airway emergency: call surgeon, open incision/remove clot at bedside if airway compromise, oxygen, prepare difficult airway/surgical airway
  • Radical neck: tumor/radiation/chemo history, consider arterial line; central access may be challenging/avoid IJV on operative side depending surgery
  • Le Fort II/III or basilar skull concerns: nasal intubation contraindicated
  • Post-tonsillectomy hemorrhage: full stomach blood, hypovolemia, two suctions, RSI with experienced airway help, correct volume/coags, PONV prevention

Geriatrics

Core concept

  • Physiologic age beats chronologic age
  • Functional reserve peaks ~30 then declines; frailty = decreased reserve/resistance to stressors
  • Frailty phenotype: ≥3 of weight loss, exhaustion, weakness/grip, slow walking speed, low activity

MAC + pharmacology

  • Volatile MAC decreases ~6% per decade after age 40; 70-year-old ≈ 18–21% decrease depending rounding
  • Decreased albumin → ↑ free fraction of acidic drugs like benzos/propofol-ish highly protein bound meds; alpha-1 acid glycoprotein often increased with age/inflammation affecting basic drugs
  • ↑ body fat → larger Vd/prolonged lipophilic drugs; ↓ TBW/lean mass → smaller Vd for hydrophilic drugs
  • Dose low/slow; increased sensitivity to opioids, benzos, sedatives; avoid anticholinergic/Beers meds when possible

Cardiovascular aging

  • ↓ beta receptor responsiveness, ↑ circulating norepinephrine, stiff ventricles/diastolic dysfunction
  • Blunted baroreflex → hypotension with induction, position changes, neuraxial sympathectomy
  • Fixed-ish CO: depend on preload/atrial kick; slower compensation to stress

Pulmonary aging

  • ↓ response to hypoxia/hypercapnia; ↑ work of breathing; ↓ chest wall compliance; V/Q mismatch
  • Closing capacity exceeds FRC supine around age 45 and upright around age 65
  • RV and FRC increase; TLC roughly unchanged; vital capacity decreases
  • Higher atelectasis/hypoxemia risk; preoxygenate, lung-protective ventilation, postop pulmonary hygiene

Renal / endocrine / thermoregulation

  • Renal mass and renal blood flow decline; GFR decreases about 1 mL/min/year after 40 → 60-year-old about 20 mL/min lower
  • Serum creatinine may look “normal” due to low muscle mass; adjust renally cleared meds
  • ↓ ability to excrete or conserve Na/water → fluid/electrolyte vulnerability
  • Impaired thermoregulation + low muscle/fat → hypothermia risk

Neurocognitive + ethics

  • Postoperative delirium = acute fluctuating confusion, disorientation/perceptual disturbances; associated with worse outcomes including mortality
  • POCD/neurocognitive disorder = more prolonged cognitive decline; regional anesthesia has NOT been proven to prevent long-term POCD
  • Triple low: low MAP + low BIS + low volatile concentration; not low pulse
  • Most periop strokes are not recognized in PACU; many recognized later
  • Ethics: autonomy, beneficence, nonmaleficence = do no harm, justice
  • Advance directives can be adjusted/clarified for surgery; discuss goals not automatic suspension

Flashcards

Tap a card to flip it. These are the “don’t miss the easy points” cards.

A-delta fibers
Myelinated; fast/sharp/localized first pain.
C fibers
Unmyelinated; slow/dull/burning/aching second pain.
Substance P
C fiber; NK-1 receptor; slow/chronic pain.
Hunter serotonin sign
Clonus is the big one; hyperthermia is also huge.
STOP serotonin tx
Stop/supportive, benzos, oxygen/intubate/paralyze if severe, cyproheptadine.
CRPS-1 vs 2
1 = no specific nerve; 2 = specific nerve injury.
Diagnostic sympathetic block
Local anesthetic, short-term.
Therapeutic sympathetic block
Alcohol, phenol, or RFA.
Paired laryngeal cartilages
Arytenoid, corniculate, cuneiform.
Unpaired cartilages
Thyroid, cricoid, epiglottis.
Internal SLN
Sensory above vocal cords.
RLN sensory
Below vocal cords.
RLN motor
All intrinsic muscles except cricothyroid.
External SLN
Cricothyroid motor.
PB
Posterior cricoarytenoid = aBducts.
LAD
Lateral cricoarytenoid = ADducts.
RAE tube meaning
Ring-Adair-Elwyn.
Armored tube trap
Flexible, but can still be occluded.
Unilateral RLN injury
Hoarseness.
Bilateral RLN injury
Stridor/respiratory distress/aphonia.
MAC aging
Decreases ~6% per decade after 40.
Closing capacity
CC > FRC supine ~45; upright ~65.
GFR aging
Drops ~1 mL/min/year after 40.
Nonmaleficence
Do no harm.
Regional and POCD
Not proven to reduce long-term POCD.

60-Question Ranalli-Style Quiz

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