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Musculoskeletal (Exam 2) Flashcards

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1
Q

What is Scleoderma?

A
  • Inflammation and autoimmunity
  • Vascular injury with vascular obliteration
  • Tissue fibrosis and organ sclerosis
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2
Q

Scleroderma: CREST Syndrome

A
  • Calcinosis: Calcium deposits in the skin
  • Raynauds Phenomenon:
  • Esopheal Dysfunction
  • Sclerodactyly : thickening and tightening of skin around fingers
  • Telangiectasias: dilation of capillaries
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3
Q

Symptoms of Scleroderma: Skin

A
  • mild thickening
  • diffuse non-pitting edema
  • taut skin
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4
Q

Symptoms of Scleroderma: MS

A
  • Limited mobility/contractures
  • skeletal muscle myopathy
  • plasma CK increased
  • mild inflammatory arthritis
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5
Q

Symptoms of Scleroderma: Nervous System

A
  • Nerve compression
  • trigeminal neuralgia
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6
Q

Symptoms of Scleroderma: CV

A
  • Systemic and Pulmonary HTN
  • dysrhythmias
  • vasospasms in small arteries of fingers
  • CHF
  • Pericarditis
  • Pericardial effussion
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7
Q

Symptoms of Scleroderma: Pulmonary

A
  • Diffuse interstitial Pulmonary Fibrosis
  • Decreased pulmonary compliance
  • arterial hypoxemia
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8
Q

Symptoms of Scleroderma: Renal

A
  • Decreased Renal Blood Flow
  • Systemic HTN
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9
Q

Symptoms of Scleroderma: GI

A
  • Xerostomia
  • poor dentition
  • fibrosis of GI tract
  • Reflux
  • dysphagia
  • malabsorption syndrome
    * Reglan does not WORK
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10
Q

Scleroderma Treatment

A
  • Alleviating Symptoms
  • ACE - Inhibitors –> Renal Protection
  • CCB –> Raynauds
  • PPIs –> Reflux
  • Pulmonary HTN –> sildanefil

Tachycardia and Bradycardia are bad

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11
Q

Scleroderma Anesthesia: Airway Concerns

A
  • Mandibular motion
  • Small mouth opening
  • Neck ROM
  • Oral bleeding
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12
Q

Scleroderma Anesthesia: CV concerns

A
  • IV/arterial line access difficulty
  • contracted intravascular volume
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13
Q

Scleroderma Anesthesia: Pulmonary Concerns

A
  • Decreased Pulmonary Compliance and Reserve
  • Avoid increased PVR (hypoxia, hypercarbia, acidosis)
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14
Q

Scleroderma Anesthesia: GI Concerns

A
  • Aspiration Risk
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15
Q

Scleroderma Anesthesia Management: Other concerns

A
  • Eyes: Corneal abrasion
  • Regional anesthesia
  • keep warm
  • VTE prophylaxis
  • Postioning
    * Pulse OX difficulties
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16
Q

What is 3x more common in Scleroderma patients than the rest of the population?

A
  • VTE (Venous Thromboembolism)
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17
Q

Pseudohypertrophy Muscular Dystrophy: Duchenne Muscular Dystrophy (DMD)

A
  • Affects the Proximal skeletal muscle groups of the pelvic girdle
  • Mutation in the dystrophin gene
  • Fatty infiltration = pseudohypertrophic
  • 2-5 y/o males
  • X chromsome link recessive trait
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18
Q

What are the initial symptoms for Pseudohypertrophy/ Duchenne Muscular Dystrophy (DMD)?

A
  • Waddling gait
  • frequent falls
  • difficulty climibing stairs
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19
Q

Pseudohypertrophy/ Duchenne Muscular Dystrophy (DMD): Timeline

A
  • Affects the Proximal skeletal muscles of the pelvic girdle
  • Wheelchair bound by 8-10
  • Deterioration in muscle strength
  • Death by 20 -25 y/r
  • Normally die from CHF and/or pneumonia
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20
Q

Pseudohypertrophy/ Duchenne Muscular Dystrophy (DMD): CNS

A
  • Intellectual disability
  • avoid NMB, low gag reflex, high asp risk
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21
Q

Pseudohypertrophy/ Duchenne Muscular Dystrophy (DMD): MS

A
  • Kyphoscoliosis
  • skeletal muscle atrophy –long bone fractures
  • serum CK 20 -100x normal
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22
Q

Pseudohypertrophy/ Duchenne Muscular Dystrophy (DMD): Pulmonary

A
  • Weakened respiratory muscle and cough
  • OSA
  • poor reserve
  • d/t weakening of the diaphragm
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23
Q

Pseudohypertrophy/ Duchenne Muscular Dystrophy (DMD): GI

A
  • Hypomotility
  • Gastroparesis — prolonged NPO times
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24
Q

Pseudohypertrophy/ Duchenne Muscular Dystrophy (DMD): CV

A
  • Sinus tachycardia
  • cardiomyopathy
  • EKG abnormlaties
  • Short PR intervals
  • tall QRS
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25
Pseudohypertrophy/ Duchenne Muscular Dystrophy (DMD): Anesthesia Concerns
* Airway: weak laryngeal reflexes and cough * Pulmonary: weakened muscles * CV: Pre-Op EKG and/or ECHO based on severity * GI: Delayed gastric emptying
26
Pseudohypertrophy/ Duchenne Muscular Dystrophy (DMD): Anesthesia Management
*** Avoid succinylcholine** * Pharnygeal and respiratory muscle weakness * Rhabdomyolysis w/ administration of halogenated anesthetics * MH -- increased incidence (Dantrolene) * **Regional > GA**
27
Myasthenia Gravis
* Chronic autoimmune disorder * NMJ -- Decreased functional post -synaptic ACH receptor * **Muscle weakness w/ rapid exhaustion of voluntary muscle** * Parial recovery with rest * ACh receptor-binding antibodies and **thymus abnormalities**
28
Myasthenia Gravis: S/S
* **Ptosis,** diplopia and dysphagia * Dysarthria (difficulty speaking) * difficulty handling saliva * Isolated respiratory failure * Arm, leg, or trunk muscle weakness * Myocarditis * Autoimmune disease associated
29
Causes and symptoms of Myasthenic Crisis
* Drug resistance or insufficent drug therapy * s/s: severe muscle weakness and respiratory failure *** WILL NEED INTUBATED**
30
Causes and symptoms of Cholinergic Crisis
* Excessive anticholinesterase treatment * **Can be caused by Neostigmine** -- **give Glycopylorated w/Neostigmine** * S/S: Muscarinic side effects -- profound muscle weakness, salivation, miosis, bradycardia, diarrhea, abdominal pain
31
Edrophonium/Tensilon Test
* 1-2 mg IV * **Improves = myasthenic crisis** * Worsens = Cholinergic Crisis
32
Myasthenia Gravis Treatment: Anticholinesterase
* First line treatment * Pyridostigmine >Neostigmine
33
Myasthenia Gravis: Thymectomy
* Induces remission * reduces use of immunosuppresives * reduces ACh receptor antibody levels * Full benefit delayed
34
Myasthenia Gravis: Immunosuppression medications
*** Corticosteroids -- most common and most effective** * Azathioprine * cyclosporine * mycophenolate
35
Myasthenia Gravis: Immunotherapy
* Plasmapheresis -- removes antibodies from circulation * Immunoglobulin -- temporary effect; no affect on circulating ACh
36
Myasthenia Gravis: Anesthesia Management
* Aspiration Risk * Weakened Pulmonary effort * Marked sensitivity to nondepolarizing muscle relaxant * resistance to succinylcholine * intermediate - acting muscle relaxant * **Intubated without NMBD** Give ROC if you have to RSI
37
Osteoarthritis
* Degenerative process affecting articular cartilage * Minimal Inflammation * Joint trauma * Pain present with motion, relieve by rest
38
Joint Trauma associated wtih Osteoarthritis
* Biomechanical Stresses * Joint injury * abnormal joint loading * neuropathy * ligament injury * muscle astrophy * obesity
39
What is the most common joint disease, leading chronic diseases of the elderly and a major cause of disability?
Osteoarthritis
40
Name (6) Osteoarthritis signs/symptoms?
* Weight bearing and distal interphalangeal joints * Herberden nodes-- distal interphalangeal joints * Degenerative Disease -- vertebral bodies and intervertebral disks * Protusion of the nuscleus pulposus * Compression of nerve roots * Middle to lower c-spine and l-spine
41
Osteoarthritis Treatment: Non medications
* PT and exercise * Maintaining muscle function * Pain Relief * Joint Replacement surgery
42
Osteroarthritis: Anesthesia Management
* Airway * Limited ROM
43
Rheumatoid Arthritis
* Autoimmune- mediated, systemic inflammatory disease * **Proximal interphalangeal and metacarpophalangeal joints** * Rheumatoid nodules at pressure points * Rheumatoid factor
44
Does Rheumatoid Arthritis occur more in Males or Females?
* Females * 2-3x more
45
Rheumatoid Arthritis: S/S overview
* Single or multiple joints * painful synovial inflammation, swelling, and increased fluid * Morning stiffness * symmetrical distribution of several joints * Fusiform swelling * Synovitis of temporomandibular joint * Affects nearly all joints
46
What joints does Rheumatoid Arthritis not affect?
* Thoracic spine * lumbarsacral spine
47
Rheumatoid Arthritis: Atlantoaxia Subluxation
* Odontoid process protrudes into the foramen magnum. * Pressure on the spinal cord or impairs vertebral artery blood flow. ----> increase risk of stroke, bowel/bladder incontinence , paraplegia/paralysis
48
Rheumatoid Arthritis: Cricoarytenoid Arthritis
* Acute -hoarsness, dysnea, and stridor w/ tenderness over larynx * **swelling and redness of arytenoids** * Chronic -- asymptomatic or variable degrees of hoarseness, dyspnea and upper airway obstruction
49
Rheumatoid Arthritis: NM
* Weakened Skeletal muscle-- adjacent to joints w/ active synovitis and neuropathy * AVOID NEUROMUSCLULAR BLOCKERS * Peripheral neuropathies
50
Rheumatoid Arthritis: CV symptoms
* Pericarditis * accelerated coronary artherosclerosis * **High risk for interoperative MI**
51
Rheumatoid Arthritis: Pulmonary symptoms
* Restricitive Lung changes (decrease in VC, lung volumes) * pleural effussion * Rheumatoid nodules can develop
52
Rheumatoid Arthritis: Hematology symptoms
* Anemia * neutropenia * elevated platelets
53
What is Keratoconjunctivitis sicca and xerostomia? What is is associated?
* Sjogens Syndrome * Rheumatoid Arthritis
54
Rheumatoid Arthritis: Treatments
* PT/OT * NSAIDs * Corticosteroids * DMARDS * Tumor Necrosis Factor inhibitors (TNF) and interleukin (IL-1) inhibitors * Surgery
55
Rheumatoid Arthritis: NSAIDS
* Decrease joint swelling, relieve stiffness, provide analgesia * COX-1 and COX-2 inhibitors
56
Rheumatoid Arthritis: Corticosteroids
* Decrease joint swelling, pain and morning stiffness
57
Rheumatoid Arthritis: DMARDS
* Disease modifying anti-rheumatic drugs * Halt or slow disease progression * **Methotrexate**
58
Rheumatoid Arthritis: Tumor Necrosis Factor and Interleukin Inhibitors
* TNF-alpha > DMARDS * IL-1 inhibitors -- slower onset and less effective
59
Rheumatoid Arthritis: Surgery
* Intractable pain, impairment of joint function, joint stabilization * Total replacement * Can help with symptoms, but not cure
60
Rheumatoid Arthritis: Anesthesia Management
1. Airway * atlantoaxial subluxation * TMJ limitation * Cricoarytenoids joints 2. Severe Rheumatoid lung disease 3. Protect eyes 4. Stress Dose -- corticosteroids
61
Systemic Lupus Erythematosus definition
* Multisystem Chronic Inflammatory * Antinuclear antibody production
62
Systemic Lupus: Typical Manifestation
* Antinuclear antibodies * Characteristic malar rash -- butterfly rash * Thrombocytopenia * Serositis * Nephritis
63
Who is the most at risk for Lupus?
* Young women and African Americans: 15-40 y/o * Pregnancy w/ nephritis and HTN = risk of exacerbation and/or poor fetal outcomes
64
What drugs can induce Lupus?
* Hydralazine * Procainamide
65
What is the most commonly assiciated rash with Lupus, beside the butterfly rash?
* Aculopapular rash * Areas that are exposed to sunlight
66
Systemic Lupus Erythematus: S/S
* Polyarthritis and dermatitis * Symmetrical arthritis -- no spinal involvement; **Avascular nectrosis of femoral head or condyle**
67
Systemic Lupus Erythematus: CNS
* **Cognitive Dysfunction** * psychological changes * anxiety, depression, migraines, fibromyalgia
68
Systemic Lupus Erythematus: CV
* **Pericarditis** * Coronary artherosclerosis * Raynaulds
69
Systemic Lupus Erythematus: Pulmonary
* Lupus pneumonia * restrictive lung disease * vanishing lung syndrome
70
Systemic Lupus Erythematus: Renal
* Glomerulonephritis * Decreased GFR * hematuria
71
Systemic Lupus Erythematus: GI/Liver
* ABD pain * pancreatitis * **elevated liver enzymes**
72
Systemic Lupus Erythematus: NM
* Skeletal muscle weakness
73
Systemic Lupus Erythematus: Hematology
* Thromboembolism * Thrombocytopenia * hemolytic anemia ASA or plavix d/t high risk
74
Systemic Lupus Erythematus: Skin symptoms
* Butterfly-shaped malar rash * discoid lesions * alopecia
75
Systemic Lupus Erythematus: Treatment
* NSAIDs or ASA * Anti-malaria --> hydrocholoquine and quinacrine * Corticosteroids * Immunosuppressants (better than steroids) --> Methotrexate, azathiprine
76
Systemic Lupus Erythematus: Anesthesia Management
* **Stress dose of Corticosteroids** * Airway: recurrent laryngeal nerve palsy, cricoarytenoid athritis * Based on mainfestation and organ dysfunction
77
Malignant Hyperthermia Overview
* **Anesthesia Specific** * Hypermetabolic syndrome * Genetic Mutation -- **Ryanadine Receptors (RYR1**) and dihydropyridine receptors * **Exposure to Inhaled VA and succinylcholine** *** 50% mortality** * **Family history** * Uncontrolled elevation of sarcoplasmic calcium * Sustained activation of muscle contractions * Rhabdomylosis
78
Malignant Hyperthermia: Non-triggering Agents
79
Malignant Hyperthermia: Early and Late s/s
80
Malignant Hyperthermia: Treatment
* D/C all triggering gas/drugs * Hyperventilation with 100% O2 @ 10L/min * Change breathing circuit and soda lime * Dantrolene * Treat Arrythmias * Monitor urine output
81
What medication do you use to treat Malignant Hyperthermia? How is it prepared?
* Dantrolene * 20 mg + 3G mannitol * mix w; 60 mL sterile water * Intial dose 2.5 mg/kg * Max Upper limit: 10 mg/kg
82
Malignant Hyperthermia: Post-Op
* Transfer to ICU 24 - 48 hours * Report to MH registery * MH testing for pt and family members -- muscle biopsy
83
Why do we use a Stellate Ganglion Block?
*** Prevents SNS surges** * i.e: Recurrent chest pain, sceroderma, long COVID, chronic pain syndrome, hyperhydrosis.
84
Homer's Syndrome
* Partial ptosis (drooping or falling of the upper eyelid) * Miosis (constricted pupil) * Facial anhidrosis (absence of sweating) due to a disruption in the sympathetic nerve supply * *** Phrenic Nerve Blockade Association * Caused by Stellate Ganglion Blockade
85
What are the 5 parts of the Brachial Plexus?
1. Root 2. trunk 3. divisions 4. cords and branches **R**ead **T**hat **D**amn **C**adaver **B**ook
86
Innervation of the Hand
87
Name the 1st sign of MH
* ETCO2
88
After your ETCO2 increases with MH, what other signs will you see?
* HR, BP, then temp
89
MH Presentation: RAT
* Rigidity * Acidosis * temp
90
Pathogenesis of MH
* genetic predisposition d/t ryanodine receptor gene mutation ----> Excessive calcium accumalation in response to certain anesthetic trigger agents. * Hypermetabolic state w/ sustained cxn and muscle breakdone (rhabdomyolysis)
91
Name the Clinical Features of MH
* Onset -- after induction * Hearalding signs: High ETCO2 and tachypnea and RAT (rigdity, acidosis, temp)
92
(4) diffentials that can mimic MH
**CATS** * Catecholamine tremor from phenochromocytoma * Acute porphyria crisis * thyrotoxicosis (thyroid storm) * sepsis
93
Management of MH
SHADE * **S**top d/c inhaled agent * **h**eat control w/ IV fluids * **A**ctivated charcoal * **D**antrolene (Rhyanodex) * **E**lectrolytes

Health Assessment (7 decks)

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