ortho Flashcards
complications of IO access
- infection: osteo, cellulitis, bacteremia, 2. compartment syndrome 3. muscle necrosis 4. growth plate injury
Benefits to regional
- Avoidance of GETA 2. improved intraop and postop pain control 3. cards: possible decrease in ichemia with thoracic epidural 4. improved post op lung fxn-decreased PNA 5. GI: improved bowel fxn w use of low dose narcotics 6. Heme: deceased blood loss and transfusion requirement (hip), decreased DVT and graft thrombosis due to reduction in periop hypercoaguable state 7. Endocrine: attenuation of stress response
How can you decrease chance of bone cement implanatation syndrome
during hardening process, it expands increasing intramedullary pressure maintain euvolemia high pressure lavage of femoral shaft to remove debris allow cement to become viscous before insertion create vent hole in femur to relieve pressure use uncemented femoral component
tourniqet side effects
hypothermia, hyperthermia in LE TQ in kids
hypotension, HTN (when inflated pain-ischemia pain mediated by umyelinated C fibers)
washout of accumulated metabolic waste, increasing PaCo2 and ETCO2, serum lactate, and K+.
PE, arterial thrombosis
nerve ischemia
signs bone cement syndrome
hypoxia, hypotension, decrease CO, dysrhythmias, pulm htn. Caused by fat/bone marrow emboli released from intramedullary pressure increase during cement hardening. This also results in release of vasoactive mediators from lung (hence pulm htn/hypoxemia). Methylmethacrylate itself can cause vasodilation too, but this is not usually clinically signif. in humans.
systemic manifestations RA
CV: pericardial thickening/pericarditis//effusion, myocarditis/fibrosis, vasculitis, AR, CAD from steriods, conduction defects, vasculitis
pulm: pleural effusion, pulm nodules, pulm fibrosis
Heme: anemia, Aspirin induced plt dysfxn, thrombocytopenia,
endocrine: adrenal insufficiency (chronic steriod use), immunesuppression from steriods and antiinflammatory meds
Joint involvement/difficult intubation: cervical spine (alantoaxial subluxation, >5mm alanto odontoid distance), TMJ, cricoarytenoid joint (hoarse voice, small ETT)= difficult intubation
liver and kidney dysfunction
triad & signs fat embolsim
Triad Dypsnea/Confusion/Petechiae, classically presents 72 hrs post long-bone/pelvic fx. Intra-op presents with decrease in ETCO2, desaturation, and pulm HTN
common drugs RA pts use to manage dz
NSAIDs: gastric ulcers, renal complications, plt dysfunction
DMARDS (slow acting over months): drug modifiying antirheumatic drugs-methotrexate, azathioprine
Steriods: rapidly decreased inflammation while DMARDs kick in-consider periop exogenous steriods if pt at risk of adrenal insufficiency (5mg/day) in last year
Issue with alanto axial subluxation
subluxation of C1 on C2 could lead to displacement of odontoid process into the cervicalspine medulla, leading to quadriparesis spinal shock and death
risk factors for TQ pain
treatment:
inadequate blockade: IV RA>epidural>spinal>GA
release TQ for 15 min
How to reduce post op thromboembolism
continuous post op epidural
intermititent leg compression devices
A/C
considerations for AS
neuro: nerve root compression, cauda equina syndrome, uvetitis, parathesia, high block 2/2 smaller epidural space, c spine/TMJ involvement
cards: AI, condution defects,
resp: restrictive lung dz, impossible trach if stuck in neck flexion, difficult airway
gi: UC, crohns
LAST tx
call for help, lipid, and code cart (hypercarbia increases cerebral blood floow and increases free fxn of drug)
ensure oxygenation/vent, intubate if needed (min acidosis from seizure induced musclea activity but not from seziure induced cerebral metabolism
benzo for seizure
lipid rescue: 1.5mg/kg (repeat every 5min), infusion 0.25mg/kg/min (can increase to 0.5), continue infusion for 10 min after cardiac stable. max 10mg/kg for 30 min
amdiodarone for arrythmia if stable, or cardioversion/defib
CBP
What drugs CI during LAST
epi high dose: arythymogenic/reduce efficiacy of lipid rescue
vasopressin: poor outcomes and pulm hemorrhae
LA: exacerbate primary cause of instability
CCB: slow cardiac conduction, negative inotrophy
BB: reduced blood flow to liver (reduction of met in amide), negative inotrophy, negative chronotrophic effect
