NAGELHOUT PHARM 2 FINAL PAPER 2026
EXAM QUESTIONS AND SOLUTIONS GRADED
A+
◉ Short Acting Nondepolarizing NMBs
(Length of duration). Answer: Mivacurium
(20-30 minutes)
◉ Intermediate Acting Nondepolarizing NMBs (4)
(Length of duration). Answer: Atracurium
Cisatracurium
Vecuronium
Rocuromium
(30-60 minutes)
◉ Long Acting Nondepolarizing NMB
(Length of duration). Answer: Pancuronium
(60-90 minutes)
◉ NMB Reversal Agents (3). Answer: Neostigmine
Edrophonium
,Sugammadex
◉ NMBs work at ____ receptors. Answer: Nicotinic Cholinergic (sub-
m)
◉ Nicotinic Cholinergic (sub-m) use positive or negative feedback?.
Answer: Positive feedback. This explains fade with NDMBs.
◉ Neurotransmitter of the NM junction. Answer: acetylcholine
◉ Breaks down acetylcholine at the NM synapse/junction. Answer:
acetylcholinesterase
◉ Phase 2, Non-depolarizing agents are: agonists or antagonists.
Answer: Antagonist
◉ Phase 1, Depolarizing agents act as: agonist or antagonist??. Answer:
Agonist then antagonist
◉ Train of Four Ratio. Answer: Strength of 4th twitch:Strength of 1st
twitch (when it is 90% patient considered recovered)
◉ Best nerve/muscle to measure onset of NMB. Answer: Facial Nerve
Orbicularis Oculi (Corrugator supercilii = best)
,(reflects diaphragm blockade)
(negative-black electrode over nerve)
◉ Best nerve/muscle to measure emergence from NMB. Answer: Ulnar
Nerve
Adductor Pollicis
Measures thumb adduction (Red proximal)
◉ Single Twitch Test. Answer: 1.0 Hz
Single stimulus
Compares pre (baseline) and post NMB hand twitch
◉ Train of Four Test. Answer: 4 - 2 Hz twitches
Compares 4th twitch to 1st twitch (fade)
Reflects 70-100% blockade
*Succ has no fade, all 4 twitches equal*
◉ Double Burst Simulation (DBS) Test. Answer: 2 - 50 Hz twitches
0.75 seconds apart
Compares 2 twitches to monitor for fade
◉ Tetanus Test. Answer: 100 Hz twitch for 5 seconds
, Painful
◉ Posttetanic Count Test. Answer: 50 Hz stimulus for 5 sec → 3 sec
pause → 1 Hz single twitch every second
Only used when patient is 100% paralyzed
0 = call for ventilator (>9 minutes til TOF)
4 = 4 minutes until TOF possible
8= 0-2 minutes until TOF
◉ Sequence of muscle paralysis. Answer: 1. Eyelids (Protective muscles
of pharynx)
2. Extremities
3. Chest (neck downward)
4. Abdominal muscles
5. Diaphragm
◉ Muscles not affected by NMBs (4). Answer: 1. Cardiac muscle
Smooth muscle:
2. Bronchi (can't treat bronchospasm with NMBs)
3. Uterus
4. GI/bowels
EXAM QUESTIONS AND SOLUTIONS GRADED
A+
◉ Short Acting Nondepolarizing NMBs
(Length of duration). Answer: Mivacurium
(20-30 minutes)
◉ Intermediate Acting Nondepolarizing NMBs (4)
(Length of duration). Answer: Atracurium
Cisatracurium
Vecuronium
Rocuromium
(30-60 minutes)
◉ Long Acting Nondepolarizing NMB
(Length of duration). Answer: Pancuronium
(60-90 minutes)
◉ NMB Reversal Agents (3). Answer: Neostigmine
Edrophonium
,Sugammadex
◉ NMBs work at ____ receptors. Answer: Nicotinic Cholinergic (sub-
m)
◉ Nicotinic Cholinergic (sub-m) use positive or negative feedback?.
Answer: Positive feedback. This explains fade with NDMBs.
◉ Neurotransmitter of the NM junction. Answer: acetylcholine
◉ Breaks down acetylcholine at the NM synapse/junction. Answer:
acetylcholinesterase
◉ Phase 2, Non-depolarizing agents are: agonists or antagonists.
Answer: Antagonist
◉ Phase 1, Depolarizing agents act as: agonist or antagonist??. Answer:
Agonist then antagonist
◉ Train of Four Ratio. Answer: Strength of 4th twitch:Strength of 1st
twitch (when it is 90% patient considered recovered)
◉ Best nerve/muscle to measure onset of NMB. Answer: Facial Nerve
Orbicularis Oculi (Corrugator supercilii = best)
,(reflects diaphragm blockade)
(negative-black electrode over nerve)
◉ Best nerve/muscle to measure emergence from NMB. Answer: Ulnar
Nerve
Adductor Pollicis
Measures thumb adduction (Red proximal)
◉ Single Twitch Test. Answer: 1.0 Hz
Single stimulus
Compares pre (baseline) and post NMB hand twitch
◉ Train of Four Test. Answer: 4 - 2 Hz twitches
Compares 4th twitch to 1st twitch (fade)
Reflects 70-100% blockade
*Succ has no fade, all 4 twitches equal*
◉ Double Burst Simulation (DBS) Test. Answer: 2 - 50 Hz twitches
0.75 seconds apart
Compares 2 twitches to monitor for fade
◉ Tetanus Test. Answer: 100 Hz twitch for 5 seconds
, Painful
◉ Posttetanic Count Test. Answer: 50 Hz stimulus for 5 sec → 3 sec
pause → 1 Hz single twitch every second
Only used when patient is 100% paralyzed
0 = call for ventilator (>9 minutes til TOF)
4 = 4 minutes until TOF possible
8= 0-2 minutes until TOF
◉ Sequence of muscle paralysis. Answer: 1. Eyelids (Protective muscles
of pharynx)
2. Extremities
3. Chest (neck downward)
4. Abdominal muscles
5. Diaphragm
◉ Muscles not affected by NMBs (4). Answer: 1. Cardiac muscle
Smooth muscle:
2. Bronchi (can't treat bronchospasm with NMBs)
3. Uterus
4. GI/bowels
