Exam 2 Musculoskeletal Diseases Flashcards
What is scleroderma?
Inflammation and autoimmune disease that causes vascular injury and vascular obliteration. Chronic hardening and tightening of the skin and connective tissues.
Tissue fibrosis and organ sclerosis.
What are the 3 forms of scleroderma?
- Localized scleroderma- skin, face, distal limb
- Limited cutaneous systems sclerosis - CREST syndrome, has prominent skin manifestations
- Diffuse cutaneous system sclerosis- generalized skin involvement and cardiac complications.
The limited symptoms of scleroderma are referred to as CREST. What does CREST stand for?
S/S of Scleroderma
Skin:
MS:
Nervous System:
CV:
Skin: Taut skin
MS: Limited mobility/contractures, skeletal muscle myopathy
Nervous System: Nerve compression
CV: Systemic and pulmonary HTN, dysrhythmias, vasospasm in small arteries of fingers, CHF
S/S of Scleroderma
Pulmonary:
Renal:
GI:
Pulmonary: Diffuse interstitial pulmonary fibrosis, decreased pulmonary compliance (stiff lungs)
Renal: Decreased renal blood flow and systemic HTN
GI: Xerostomia (dry mouth), poor dentition, fibrosis of GI tract (no Reglan, will not stimulate fibrotic GI tract), reflux
Scleroderma Treatment
Alleviating symptoms…
ACE inhibitors for renal protection - only treatment that has been proven to alter the course of scleroderma
SclerodermaAnesthesia Management and Considerations
Airway:
IV:
Pulmonary:
GI:
Eyes:
Other:
Airway: Mandibular motion, small mouth opening, neck ROM (do not manipulate neck while asleep), oral bleeding
CV: IV/arterial line access may be difficult, use US.
Pulmonary: Decreased pulmonary compliance and reserve, avoid increasing PVR (do not make them hypoxic)
GI: Aspiration caution, increase gastric pH by using PPI.
Eyes: tape eyes, ointment, gauze, goggles
Other: Regional anesthesia may be best for these patients, keep patient warm, VTE prophylaxis, Positioning with care, Pulse ox difficulties (ear probe)
What is Pseudohypertrophy Muscular Dystrophy/ Duchenne Muscular Dystrophy (DMD)
Mutation in the dystrophin gene (x-linked recessive) causes fatty infiltration leading to pseudohypertrophic muscles.
Common in 2-5 y/o boys
By age 8-10 Wheelchair bound
Usually live until ages 20-25 years (CHF, pneumonia)
Initial symptoms of Duchenne Muscular Dystrophy
Initial symptoms: waddling gait, frequent falling, difficulty climbing stairs, tiptoes.
Duchenne Muscular DystrophyS/S
CNS:
MS:
CV:
Pulmonary:
GI:
CNS: Intellectual disability
MS: Kyphoscoliosis, skeletal muscle atrophy, serum CK 20-100x normal d/t increase muscle permeability
CV: Sinus tachycardia, cardiomyopathy, EKG abnormalities (tall R-wave in V1)
Pulmonary: OSA, weakened respiratory muscles, and cough
GI: Hypomotility, gastroparesis
Duchenne Muscular DystrophyAnesthesia Management
Airway:
Pulmonary:
CV:
GI:
Airway: weak laryngeal reflexes and cough (You want these patients “singing” on the tube during emergence.)
Pulmonary: weakened muscles
CV: Pre-op EKG and/or echo based on the severity
GI: Delayed gastric emptying, aspiration risk
Other anesthesia management for Duchenne Muscular DystrophyAnesthesia:
What drug do you want to avoid?
When do you want to extubate these patients?
What type of incidence are higher in these patients?
What type of anesthesia may be best?
Avoid succinylcholine can cause hyperkalemia and rhabdomyolysis. Use NDMR (Rocuronium).
Pharyngeal and respiratory muscle weakness, secure the airway. Make sure the patient is fully awake.
MH – increased incidence. Have Dantrolene ready. Use TIVA as an alternative
Regional Anesthesia may be best than GA.
What is Myasthenia Gravis?
A chronic autoimmune disorder involving the NMJ. There will be decreased functional post-synaptic AChreceptors.
Muscle weakness w/ rapid exhaustion of voluntary muscles. Partial recovery with rest.
ACh receptor-bindingantibodies are linked to thymus abnormalities.
Myasthenia GravisS/S
Eyes:
Oral:
Pulmonary:
Skeletal:
Heart:
Endocrine:
Ptosis (droopy eyelid), diplopia (double vision)
Dysarthria (slurred speech), dysphagia, and difficulty handling saliva
Isolated respiratory failure (rare)
Arm, leg, or trunk muscle weakness
Myocarditis
Autoimmune diseases associated
RA, SLE, pernicious anemia, hyperthyroidism
Differentiate between Myasthenia GravisMyasthenic Crisis vs Cholinergic Crisis.
What is the effect of the Edrophonium/Tensilon Test in each condition?
Myasthenic crisis:
D/t drug resistance or insufficient drug therapy
S/S: severe muscle weakness and respiratory failure
Cholinergic crisis (SLUDGE):
D/t excessive anticholinesterase treatment
S/S: muscarinic side effects – profound muscle weakness, salivation, miosis, bradycardia, diarrhea, abdominal pain
Edrophonium/Tensilon Test:
1-2 mg IVPof edrophonium will improve the myasthenic crisis and makes the cholinergic crisis worse.
Myasthenia GravisTreatment
Anticholinesterases (first-line treatment):
Thymectomy (when will you see results):
Immunosuppression:
Immunotherapy:
Anticholinesterases:
The first line of treatment
Pyridostigmine last longer than neostigmine
Thymectomy:
Induces remission
Reduced use of immunosuppressives
Reduces ACh receptor antibody levels
Full benefit delayed (2-6 months)
Immunosuppression
Corticosteroids, azathioprine, cyclosporine, mycophenolate
Immunotherapy (short-term effect)
Plasmapheresis will remove antibodies from circulation.
Immunoglobulin will have a temporary effect.
Myasthenia GravisAnesthesia Management
Weakened ________ effort
Marked sensitivity to ______
Resistance to ____________
Weakened pulmonary effort (Aspiration risk)
Marked sensitivity to nondepolarizing muscle relaxants (decrease amount). Use nerve stimulator and titrate to nerve stimulator
Resistance to succinylcholine (might need a higher dose for effect, but this can lead patients into MG Crisis, just avoid using Sux)
What is Osteoarthritis?
This is the most common joint disease in the ____?
OA is characterized by _________ inflammation.
Does stiffness fade throughout the day?
Degenerative process affecting articular cartilage, the most common joint disease in the elderly.
Characterized by minimal inflammation usually a result of chronic joint trauma (sports), biomechanical stresses, joint injury, abnormal joint loading, neuropathy, ligament injury, muscle atrophy, and obesity.
Pain present with motion,relieved by rest. Morning stiffness fades throughout the day. (T-rex)
What joints will osteoarthritis affect?
Weight-bearing and distal interphalangeal joints.
Heberden nodes- Distal interphalangeal joints, first knuckle (pictured)
Protrusion of the nucleus pulposus (herniated disc) can lead to compression of nerve roots.
Degenerative disease – vertebral bodies and intervertebral disks. OA will affect the breakdown of the cartilage of the joints and discs in the neck and lower back. Middle to lower C-spine and L-spine.
OsteoarthritisTreatment
PT and exercise
Maintaining muscle function
Pain relief - heat, simple analgesics, anti-inflammatory drugs, transcutaneous nerve stimulator, acupuncture. OA patients are typically NOT on steroids
Joint replacement surgery - necessary when pain is debilitating
OsteoarthritisAnesthesia Management
Airway
Be aware of limited ROM, and keep them comfortable.
Document the patient’s position on the OR table.
Don’t lean on the patient.
What is Rheumatoid Arthritis?
An autoimmune-mediated, systemic inflammatory disease that usually affects the proximal interphalangeal and metacarpophalangeal joints (2nd & 3rd knuckle).
Rheumatoid nodules at pressure points (elbows)
Rheumatoid factor (IG antibody present in 95% of patients with RA)
Characteristics of Rheumatoid Arthritis
Single or multiple joints
Painful synovial inflammation, swelling, and increased fluid
Morning stiffness like OA, but remains stiff throughout the entire day.
Symmetrical distribution of several joints.
Fusiform swelling - Joints become enlarged and the fingers crooked (pictured)
Synovitis of the temporomandibular joint (decrease mouth opening)
Affects nearly all joints (except the t-spine and lumbosacral spine)
Rheumatoid Arthritis S/S
Atlantoaxial subluxation:
Cricoarytenoid arthritis:
Osteoporosis
NM
Atlantoaxial subluxation instability (C1 and C2): Odontoid process (dens) protrudes into the foramen magnum. The instability can place pressure on the transverse ligament and spinal cord. Instability can also impair vertebral artery blood flow.
Cricoarytenoid arthritis:
Acute – hoarseness, dyspnea, and stridor w/ tenderness over the larynx; swelling and redness of arytenoids
Chronic – asymptomatic or variable degrees of hoarseness, dyspnea, and upper airway obstruction
Osteoporosis: More common in women than men
NM: Weakened skeletal muscles (peripheral neuropathies)
Rheumatoid ArthritisS/S
CV:
Pulmonary:
Hematology:
Dryness:
CV: Pericarditis, accelerated coronary atherosclerosis
Pulmonary: Restrictive lung changes, decrease Vt
Hematology: anemia, neutropenia, elevated platelets
Dryness: Keratoconjunctivitis sicca (dry eyes) and xerostomia (dry mouth)
Rheumatoid ArthritisTreatment
NSAIDS
Corticosteroids
DMARDs May take 2-6 months to see effects
Tumor necrosis factor (TNF-alpha) inhibitors and interleukin(IL-1) inhibitors.
TNF-alpha inhibitors work faster than DMARDs.
IL-1 inhibitors – slower onset and less effective.
Surgery is usually held off until the patient is in intractable pain, has impairment ofjoint function, and is in need of jointstabilization. Usually a total replacementsurgery.
Rheumatoid ArthritisAnesthesia Management
Airway- Atlantoaxial subluxation ,TMJ limitation, Cricoarytenoid joints. (handle w/care)
Severe rheumatoid lung disease
Protect eyes - Keratoconjunctivitis sicca (dry eyes)
Stress dose - give before surgery, may have a decrease amount of endogenous cortisol.
What is Systemic Lupus Erythematosus?
Typical Manifestation:
Multisystem chronic inflammation characterized by antinuclear antibody production.
Typical manifestations (Usually will have 3 out 5 of the following):
1. Antinuclear antibodies
2. Malar rash (butterfly rash)
3. Thrombocytopenia
3. Serositis- inflammation of a serous membrane around the organ
5. Nephritis
Systemic Lupus ErythematosusS/S
Join/Spine:
CNS:
CV:
Pulmonary:
Renal:
Joint/Spine: Polyarthritis and dermatitis, symmetrical arthritis (most common sx), no spinal involvement, avascular necrosis of the femoral head or condyle
CNS: Cognitive dysfunction, psychological changes
CV: Pericarditis, coronary atherosclerosis, Raynaud’s
Pulmonary: Lupus pneumonia, restrictive lung disease, vanishing lung syndrome
Renal: Glomerulonephritis, decreased GFR, risk of renal failure
Systemic Lupus ErythematosusS/S
GI/Liver:
NM:
Hematology:
Skin:
GI/Liver: ABD pain, pancreatitis, elevated liver enzymes
NM: Skeletal muscle weakness
Hematology: Thromboembolism, thrombocytopenia, hemolytic anemia,
Skin: Butterfly-shaped malar rash, discoid lesions, alopecia
Systemic Lupus ErythematosusTreatment
NSAIDs or ASA - will treat arthritis and serositis
Anti-malarial (Hydroxychloroquine and quinacrine) - will treat arthritis and dermatological manifestations
Corticosteroids- By reducing inflammation, corticosteroids can help to improve the production and survival of platelets in the bone marrow.
Immunosuppressants will be used if steroids are not effective (Methotrexate, azathioprine)
Systemic Lupus ErythematosusAnesthesia Management
Based upon manifestations and organ dysfunction
Airway: recurrent laryngeal nerve palsy (common), cricoarytenoid arthritis
Stress dose of corticosteroids
What is recurrent laryngeal nerve palsy?
How does lupus cause recurrent laryngeal nerve palsy?
A condition where the nerve that controls the muscles of the larynx (voice box) is damaged, which can lead to problems with speaking, breathing, and swallowing.
In lupus, the immune system attacks healthy tissues, including the nerves. This can lead to inflammation of the laryngeal nerve or blood vessels, which can cause them to become compressed or damaged.
What is Malignant Hyperthermia?
Hypermetabolic syndrome involving a genetic mutation to the Ryanodine receptor - RYR1 gene or Dihydropyridine receptor
Caused by exposure to inhaled VA and succinylcholine (50% mortality, investigate family history)
Uncontrolled elevation of sarcoplasmic calcium
Sustained activation of muscle contraction
Rhabdomyolysis
Malignant HyperthermiaNon-triggering Agents
Malignant HyperthermiaS/S
Early Sign: Masseter, Acidosis, T-peaked, CO2 increase, HR increase, Rigidity, RR increase. MATCHRR
Malignant HyperthermiaTreatment
D/C all triggering gas/drugs
Hyperventilate with 100% O2 at 10 L/min
Change breathing circuit and soda lime
Dantrolene (Have someone else do this, hard to mix)
20 mg + 3 G mannitol (Mix with 60 mL sterile water)
Initial dose 2.5 mg/kg
Max upper limit 10 mg/kg
Treat arrhythmias
ICE, cool them down
Monitor urine output
Malignant HyperthermiaPost-Op
Transfer to ICU 24-48 hours
Report to MH registry
MH testing for pt and family members:
Muscle biopsy contracture testing (Halothane plus caffeine contracture test)
What type of anesthesia would be used if you know the patient has a history of MH?
Use TIVA and go slow.
_________ nerve fibers carry ________ information towards the CNS.
Afferent; sensory
_________ nerve fibers carry _______ signals from the brain to the periphery.
Efferent; motor
Myelinated nerve fibers are _______ than non-myelinated.
Faster
The fastest type of motor nerve fibers are____.
A alpha
The nerve fiber responsible for tactile and proprioception sensory are ________.
A beta
The nerve fiber responsible for motor function of muscle tone are ______.
A gamma
Nerve fiber responsible for pain, cold temperature, and touch sensory information
A delta
______ fibers are slow and non-myelinated.
C nerve fibers
_______ nerves are not as susceptible to peripheral blocks
motor
This is good because we can block pain without impairing motor function!
Where is the cervical plexus located?
It is located in the posterior triangle of the neck, halfway up the sternocleidomastoid muscle, and within the prevertebral layer of cervical fascia.
What is the cervical plexus formed by?
It is formed by the anterior rami (divisions) of cervical spinal nerves C1-C4.
Where is the stellate ganglion located?
What type of nerves is it comprised of?
It is found anterior to the neck of the first rib. It may extend to being anterior to the transverse process of C-7
It is comprised of SYMPATHETIC nerves!
Where is the brachial plexus found, and what part of the body does it supply?
It is formed by C5-T1 and can be found between the anterior and middle scalene muscles and then travels distally around the axillary artery. It supplies the upper extremity.
What causes Horner’s Syndrome?
It results from paralysis of the sympathetic cervical chain (stellate ganglion) which can be related to phrenic nerve blockade.
What are the s/s of Horner’s syndrome?
-partial ptosis (drooping or falling of the upper eyelid)
-miosis
-facial anhidrosis (unilateral absence of sweating)
If you were to do a nerve block at the “roots” of the brachial plexus, how much of the upper extremity would that affect?
It would cause loss of sensation in the shoulder and most of the upper arm.
Also called the interscalene block!
If you were to provide a nerve block in the trunks of the brachial plexus, what part of the upper extremity would be affected?
It would block from the mid-humerous level and below.
Also called the suprascalene block!
What spinal roots feed the axillary nerve and what are its functions?
Spinal roots: C5 and C6
Sensory functions to the upper lateral cutaneous area of the lower deltoid.
It also has motor functions to the teres minor and deltoid muscles.
What nerve roots feed the musculocutaneous nerve?
C5-C7
What function is the musculocutaneous nerve responsible for?
-Provides motor function to the muscles in the anterior compartment of the arm.
-Provides sensory function in the lateral aspect of the forearm
motor function high, sensory function low
What nerve roots feed the median nerve.
C6-T1
(also contains fibers from C5 in some individuals
What functions is the median nerve responsible for?
Motor functions: Innervates the flexor and pronator muscles in the anterior compartment of the forearm.
Sensory functions: in the lateral aspect of the palm and the lateral threes and a half fingers on the palmer surface of the hand
What nerve roots feed the radial nerve?
C5-T1
** the radial nerve “spirals” around the upper extremity
What functions is the radial nerve responsible for?
Motor: innervates the triceps brachii and the extensor muscles in the forearm.
Sensory: Innervates most of the skin of the posterior forearm, the lateral aspect of the dorsum of the hand, and the dorsal surface of the lateral three and a half digits.
What nerve roots contribute to the ulnar nerve?
C8-T1
What functions is the Ulnar nerve responsible for?
Motor: Two muscles of the anterior forearm , intrinsic muscles of the hand
Sensory: medial one and a half fingers and the associated palm area.
Innervation of the hand review
Lower extremity sensory innervation
How is the lumbar plexus structural organized?
The anterior rami of the L1-L4 spinal roots divide into several cords. They then combine together to form the six major peripheral nerves of the lumbar plexus.
What is the first major branch of the lumbar plexus?
Iliohypogastric
First branch off of L1
What is the function of the iliohypogastric nerve?
Motor: innervates the internal oblique and transversus abdominis
Sensory: Innervates the posterolateral gluteal skin in the pubic region.
Where can you find the ilioinguinal nerve?
It is the second branch off the L1 nerve root which is a part of the lumbar plexus.
What is the function of the ilioinguinal nerve?
Motor: innervates the internal oblique and transversus abdominis
Sensory: Innervates the skin on the superior antero-medial thigh. Also innervates the genitalia.
What nerve roots feed the lateral femoral cutaneous nerve?
L2 and L3
It is a part of the lumbar plexus
What function is the lateral femoral cutaneous nerve responsible for?
This nerve has a purely sensory function. It innervates the anterior and lateral thigh down to the level of the knee.
What nerve roots of the lumbar plexus feed the obturator nerve?
L2, L3, and L4
What functions is the obturator responsible for?
Motor: innervates the muscles of the medial thigh.
Sensory: Innervates the skin over the medial thigh
Which nerve roots of the lumbar plexus feed the femoral nerve?
L2, L3, and L4
What functions is the femoral nerve responsible for?
motor: innervates the muscles of the anterior thigh
Sensory: Innervates the skin on the anterior thigh and medial thigh
What nerve roots form the sacral plexus?
The plexus is formed by the anterior of S1-S4. It also receives contributions from L4-L5
What is the largest nerve of the body?
The sciatic nerve
What nerve roots of the sacral plexus feed the sciatic nerve?
L4-S3
What functions is the sciatic nerve responsible for?
Motor: Innervates the posterior thigh and the hamstring portion of the adductor magnus. Indirectly innervates all of the muscles of the leg and foot.
Sensory: no direct sensory functions. Indirectly innervates the whole leg via terminal branches.
What main nerve (before it branches) is responsible for the sensory and motor function of the bottom of the foot?
Tibial Nerve
