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Exam 2 - Musculoskeletal Diseases Flashcards

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1
Q

Systemic Sclerosis is another name for?

A

Scleroderma

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2
Q

What are the 3 processes that characterize scleroderma?

A
  1. Autoimmune-mediated inflammatory vasculitis
  2. Fibrosis of skin and internal organs from abnormal deposition of extracellular collagen
  3. Microvascular changes produce tissue fibrosis and organ sclerosis
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3
Q

What are the 3 main forms of scleroderma?

A
  • Localized (just skin)
  • Limited cutaneous
  • Diffuse cutaneous (rapidly progressing with CV complications)
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4
Q

What mnemonic guides the main symptoms associated with scleroderma?
Expound on the mnemonic.

A
  • Calcinosis
  • Raynaud’s
  • Esophageal reflux
  • Sclerodactyly
  • Telangiectasia’s
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5
Q

What skin and musculoskeletal abnormalities might be seen with scleroderma?

A
  • Taut skin
  • Contractures & myopathy
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6
Q

What can happen to nerves with scleroderma?

A

Compression

Careful when placing lines

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7
Q

What are the CV changes seen in scleroderma?

A
  • Systemic and Pulmonary HTN (careful on induction; etomidate)
  • Dysrhythmias
  • Vasospasms of small arteries in fingers
  • CHF
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8
Q

What is keratoconjunctivitis sicca?

A

Dry, red eyes from keratin deposits

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9
Q

What severe kidney issue can be caused by scleroderma?
Treatment?

A

Renal crisis - precipitated by steroids
Tx: ACEi

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10
Q

Pulmonary complications with scleroderma?

A
  • Diffuse pulmonary fibrosis
  • Decreased compliance
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11
Q

What are the GI symptoms with scleroderma?
What treatments are/are not effecive?

A
  • Decreased motility
  • Xerostomia (mouth dryness)
  • Malabsorption syndrome
  • Pseudo obstruction

Tx: Hypomotility - Octreotide; Reglan does not work

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12
Q

What treatments are used for scleroderma and their effects?

A
  • Symptom alleviation
  • ACE-inhibitors - renal protection
  • PDE inhibitors - decrease pulm HTN
  • Digoxin - improve CO
  • Steroids/Immunosupressive therapy - target organ involvement
  • PPIs - reflux
  • CCB - Raynauds
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13
Q

What airway and pulmonary anesthetic considerations exists for scleroderma?

A
  • Pulmonary fibrosis (↓ compliance/reserve)
  • Decreased ROM for airway
  • Oral bleeding (can give TXA topically)
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14
Q

What CV anesthetic considerations exists for scleroderma?

A
  • Difficult IV/arterial access
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15
Q

What non-airway/CV anesthetic managements can we do for patients with scleroderma?

A
  • Regional anesthesia
  • Pre-warm and keep warm
  • VTE prophylaxis (3x more prone to embolism)
  • Stress dose their steroids
  • Positioning d/t contractures
  • Pulse ox difficulty
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16
Q

What is Duchenne’s Muscular Dystrophy (DMD)?
What initial symptoms are present at 2-5 years of age?

A
  • X-linked dystrophin mutation resulting in muscle atrophy.
  • (Ages 2-5) = waddling gait, frequent falling, can’t climb stairs, Gower’s sign.
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17
Q

What s/s are seen with DMD?

List:
CNS
Musculoskeletal
CV
Pulm
GI

A
  • CNS - intellectual disability
  • MS - kyphoscoliosis, muscle atrophy, ↑ CK
  • CV - ↑ HR, cardiomyopathy, short PR & tall R-wave in V1, deep Q wave in limb leads
  • Pulm - weakened respiratory muscles and weak cough (related to 30% of deaths), OSA
  • GI - hypomotility & gastroparesis
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18
Q

What is pseudohypertrophic DMD?

A

Fatty infiltration, making muscles appear larger - most severe and and common form of childhood muscular dystophy

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19
Q

What are the anesthetic concerns and interventions relevant to DMD patients?

  • Airway
  • Pulmonary
  • CV
  • GI
A
  • Airway - weak laryngeal reflexes & cough
  • Pulm - weakened muscles, increased secretions (may need vent support post op)
  • CV - Get pre-op EKG & echo
  • GI - delayed gastric emptying
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20
Q

What drug should be avoided with DMD patients?

A
  • Succinylcholine (Rhabdo, ↑K⁺, increased risk of MH)

use NDMBs

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21
Q

What type of anesthesia is prefereable for a DMD patient?

A

Regional (vs GA)

But not easy to do on a child

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22
Q

Why might one use less volatile gasses with DMD patients?

A
  • DMD patients have ↑risk of malignant hyperthermia.

Ensure you have Dantrolene

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23
Q

What is the pathophysiology of myasthenia gravis?

A
  • ↓ function of NMJ post-synaptic ACh receptors.
  • Results in muscle weakness and rapid exhaustion of voluntary muscles

αlpha sub-units of ACh receptor are bound by antibodies.

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24
Q

What organ is linked with the production of anti-ACh antibodies?

A
  • Thymus
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25
Which condition is characterized by partial recovery with rest?
Myasthenia Gravis
26
What are MuSK antibodies?
* Muscle-specific kinase; present in 10% of MG patients * Loss of ACh receptors and a change in the structure of the post-synaptic folds * No thymic involvement 
27
What is type 1 and 4 MG classifications?
Type 1: limited to involvement of extraocular muscles Type 4: Severe from of skeletal muscle weakness
28
What are the initial s/s of MG?
* Ptosis * Diplopia * Dysphagia * Dysarthria (trouble speaking)
29
What may a patient with MG present to the ED for?
Isolated respiratory failuire
30
What disorders are associated with MG?
- RA - SLE - Pernicious anemia (B12 deficiency) - Hyperthyroidism
31
What abx can trigger MG symptoms?
Mycins (gentamicin, streptomycin, tobramycin)
32
Differentiate Myasthenic Crisis and Cholinergic Crisis.
- **Myasthenic Crisis** - Insufficient drug therapy resulting in severe muscle weakness and respiratory failure. - **Cholinergic Crisis** - too much -stigmine drug (excess ACh) = SLUDGE-M symptoms.
33
What test is used to diagnose myasthenia gravis?
Edrophonium/Tensilon Test - 1-2 mg IVP - Myasthenia symptoms improve with injection - If cholinergic crisis, symptoms will worsen
34
What drugs are the firstline treatment for Myasthenia Gravis? What invasive treatment would be done if drugs were ineffective?
- Pyridostigmine (max dose 120 mg q3h) - Surgical Thymectomy
35
What drugs/treatments other than pyridostigmine or surgery could be used for myasthenia gravis?
- Corticosteroids - Azathioprine - Cyclosporine - Mycophenolate - Plasmapheresis - Immunoglobulin
36
What is the most commmonly used/most effective treatment for MG?
Corticosteroids - used when muscle weakness is not controlled by anticholinesterase tx
37
What anesthetic considerations exist for myasthenia gravis?
- Aspiration risk & weakened respiratory muscles. (Give H2 antagonist and reglan) - Sensitivity to NMBs (intubate without if possible - should be easier d/t intrinsic muscle weakness) - **No succinylcholine** (resistant to it from pyridostigmine )
38
Which muscle should you not not check TO4 on MG patients?
* Adductor Pollicis * Orbicularis Oculi will overestimate degree of blockade
39
What is osteoarthritis (OA)? What makes the pain better?
- Degeneration of articular cartilage with minimal inflammation. - Pain **better at rest**. - Pain is **worse with motion**.
40
What are Heberden nodes? What disease process do they indicate?
- Bony swellings of the distal interphalangeal joints. - Osteoarthritis
41
What spinal complications occur from osteoarthritis?
- Vertebral degeneration - Nucleus pulposus herniation - Nerve root compression
42
What are the treatments for osteoarthritis?
- **PT & exercise** - Maintenance of muscle function - Pain relief - Joint replacement surgery - No corticosteroids
43
What anesthetic considerations exist for OA?
- Limited airway ROM - may require fiberoptic or video laryngoscopy
44
What is rheumatoid arthritis? What hand condition is often seen on inspection?
- Auto-immune systemic inflammatory disease - Swelling of the **Proximal** Interphalangeal, metocarpophalangeal, and elbow joints. - 2-3x higher in women than men
45
What type of swelling presents with RA?
Fusiform
46
What joints are usually spared by rheumatoid arthritis?
- Thoracic & Lumbosacral spine
47
With this condition it is common to have synovitis of the temporomandibular joint.
Rheumatoid Arthritis
48
Patients with this disorder have morning stiffness that gets better throughout the day?
RA
49
Why would the sniffing position and thus intubation be affected in a patient who has rheumatoid arthritis?
- Atlantoaxial subluxation (odontoid process pushes on spinal cord) - Cricoarytenoid arthritis (hoarseness, dyspnea, and upper airway obstruction may be present)
50
What cardiac symptoms can be seen with RA? Pulmonary?
- CV: Pericarditis and accelerated CAD - Pulm: Restrictive lung changes, rheumatoid nodules (resembles TB on xray)
51
What two facial symptoms are often seen with RA? These are manifestations of what syndrome?
- Keratoconjunctivitis sicca (dry eye) - Xerostomia (dry mouth) - Sjogren syndrome
52
What hematologic symptoms are seen in RA?
* Anemia of chronic disease * neutropenia * elevated platelets
53
What drugs are used to treat rheumatoid arthritis?
- NSAIDs - Corticosteroids - DMARDs - TNF-α inhibitors & Interleukin-1 inhibitors
54
What are the side effects of COX-1 and COX-2 inhibitors?
**COX-1 inhibitors**:  GI irritation and platelet inhibition; decrease renal blood flow and GFR **COX-2 inhibitors**: fewer GI side effects and do not interfere with platelet function; decrease renal blood flow and GFR **Increase risk of CVA and CAD**
55
Compare and contrast DMARDs vs TNF-α inhibitors & Interleukin-1 inhibitors in how they treat rheumatoid arthritis.
- DMARDs (methotrexate) slow disease progression but can take 2-6 months to see effects - TNF-α & IL1 inhibitors generally work better than DMARDs (IL1's are slower onset and less effective than TNF)
56
What drug can be given to prevent methotrexate toxicity?
Folic acid
57
What anesthesia considerations exist for rheumatoid arthritis?
- Airway complications by atlantoaxial subluxation or TMJ. - Severe RA lung disease - Stress dose steroids may be necessary
58
What pathology is this and what are these lesions called?
- Discoid lesions characteristic of SLE.
59
What type of rash is depicted below? What pathology is it characteristic of? What often causes it?
- Maculopapular rash characteristic of SLE and exposure to the sun.
60
What CV symptoms are seen with SLE?
- Pericarditis (most common) - CAD - Raynaud's
61
What type of arthritis is seen with SLE?
- Symmetrical w/ no spinal involvement but involves avascular necrosis of femoral head
62
What pulmonary symptoms are characteristic of SLE?
- Lupus pneumonia - Vanishing Lung syndrome (elevated diphragm, recurrent atelectasis) - Restrictive lung disease
63
What are the CNS s/s in SLE?
- Cognitive dysfunction - Anxiety/depression - Atypical migraines
64
What are the renal s/s in SLE?
- Glomerulonephritis - Hematuria - Decreased GFR (oliguric renal failure)
65
What treatment can accelerate death via coronary atherosclerosis in patients with SLE?
Corticosteroids
66
Hematologic s/s in SLE?
- Thromboembolism - Thrombocytopenia - Hemolytic anemia
67
GI s/s in SLE?
- Abd pain - Pancreatitis - ↑ Liver enzymes
68
What drugs are utilized to treat SLE?
- NSAIDs or ASA - Antimalarials (HCQ & quinacrine) - Corticosteroids (major cause of morbidity) - Immunosuppressants (methotrexate, azathioprine)
69
What anesthesia considerations exist for SLE patients?
- Recurrent laryngeal nerve palsy (difficulty speaking) - Cricoarytenoid arthritis - Stress dose steroids likely necessary
70
What pathophysiology causes malignant hyperthermia? Mortality rate?
* Genetic mutation of ryanidine and dihydropyridine receptor * 50%
71
What patho causes rhabdo in MH? Hyperthermia?
* Sustained high levels of sarcoplasmic Ca2+ that rapidly drives skeletal muscle into a hypermetabolic state * Increased activity of pumps and exchangers trying to correct the increase in sarcoplasmic Ca2+ associated with triggered MH increases the need for ATP, which in turn produces heat
72
What are the early signs of malignant hyperthermia?
- ↑CO₂ - ↑HR - ↑RR - Jaw muscle spasm (biting down on ETT) - Peaked T waves - Acidosis - Muscle rigidity
73
What are the late signs of malignant hyperthermia?
- Hyperthermia - Rhabdo & cola-urine - ↑CPK - VTach/Vfib (from hyperkalemia) - Acute renal failure - DIC
74
Can you give nitrous to someone with a history of MH?
Yes Just not succ or volatiles
75
What is initial Dantrolene dosing? What is the max dose? How does it help MH?
- Initial: 2.5mg/kg - Max: 10mg/kg - Reduces the concentration of sarcoplasmic Ca2+ to below contractile threshold
76
What should be done immediately if MH is suspected?
- Stop all triggering agents - Hyperventilate with 100% O2 at 10 L/min - Change breathing circuit and soda lime
77
What other drugs besides dantrolene are used to treat the effects of MH?
78
What should be done post op for MH patients?
- Transfer to ICU - Report to MH registry - MH testing for pt and family members (muscle biopsy contracture testing w/ halothane and caffiene)
79
# Kahoot 2 MH triggers?
- Isoflurane - Anectine (succinylcholine)
80
# Kahoot Horners syndrome occurs as a result of which blockade?
Stellate ganglion

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