Musculoskeletal Flashcards
CREST are characteristics of which disease process?
Scleroderma
What does CREST stand for?
C- Calcinosis, calcium deposits in skin
R- Raynaud’s
E- Esophageal dysfunction/acid reflux
S- Sclerodactyly, thickening and tight skin on fingers and hands
T- Telangiectasias, dilation of capillaries looks like red freckles
What are the 3 main forms of scleroderma?
Localized- involvement of the skin of face, trunk, and distal limbs
Limited cutaneous system sclerosis - usually combination of CREST
Diffuse cutaneous system sclerosis- rapidly progressive disease with involvement of multiple organ systems
Signs you may see in patient with undiagnosed pulmonary HTN
JVD, enlarged RV on xray
What drug does not improve intestinal hypomotility in scleroderma?
metoclopramide (reglan)
Corticosteroid use in scleroderma treatment can lead to what?
Renal crisis- treatment ACE-i
What drugs improve intestinal hypomotility in scleroderma?
Somatostatin analogues - octreotide
What are potential airway concerns in scleroderma?
poor mandibular motion, small mouth opening, limited neck ROM, oral bleeding/friable tissue
What are potential anesthesia CV concerns with scleroderma
difficult IV/arterial line access
What are potential pulmonary concerns in patients with scleroderma ?
Decreased pulmonary compliance and reserve, avoid increasing PVR (hypoxia, hypercarbia, acidosis).
Which disease process is 3x more likely to have VTE
scleroderma
What is the stress dose for steroids?
100mg q6hrs
What is the function of dystrophin?
Large protein that plays a major role in stabilization of the muscle membrane and signaling between the cytoskeleton and extracellular matrix.
What is the cause of Duchenne Muscular Dystrophy (DMD)?
mutation in the dystrophin gene
What age is DMD commonly seen and what are the signs?
2-5year old (primarily affects boys)
initial symptoms: waddling gait, frequent falling, difficulty climbing
Dystrophin is a gene located on which chromosome? dominant or recessive?
X, recessive
DMD is characterized by
muscle wasting
What lab value would be abnormal in DMD?
serum CK likely 20-100x higher than normal
What EKG characteristics would been seen in patient with DMD?
Short PR interval, sinus tachycardia, V1- tall R waves, limb leads deep Q waves
What pulmonary complications are seen in DMD?
weakened respiratory muscles and cough, loss of pulmonary reserve, increased secretions (aspiration risk), OSA, pulmonary HTN
Which medications should be avoided during anesthesia of patient with DMD?
neuromuscular blockers, volatile anesthetics, precedex
Which medication works well for sedation of children?
Ketamine - can be given intranasally
What is the ideal form of anesthesia choice in patients with DMD
regional anesthesia - avoids many risks of GA, provides postop analgesia, and facilitates chest physiotherapy
Myasthenia gravis is characterized by
exacerbations and remissions
Myasthenia gravis is a ________ type of disease that targets what?
autoimmune disease, antibodies target alpha-subunit of the ACh receptor at the NMJ
What is type 1 myasthenia gravis classification?
Limited to involvement of the extraocular muscles
-if confined to extraocular muscles for 2 years, unlikely disease progression
What is type 2a myasthenia gravis classification?
slowly progressive, mild form of skeletal muscle weakness (spares respiratory muscles)
Which classification of myasthenia gravis responds well to anticholinesterases and corticosteroids?
Type 2a
What is type 2b myasthenia gravis classification?
rapidly progressive, more severe form of skeletal muscle weakness (may involve respiratory muscles)
-does not respond as well to drug therapy
What is type 3 myasthenia gravis classification?
Acute onset and rapid deterioration of skeletal muscle strength within 6months
- high mortality rate
What is type 4 classification of myasthenia gravis classification?
Severe form of skeletal muscle weakness - progression from type 1 or 2
What are common s/sx of myasthenia gravis?
Ptosis, diplopia and dysphagia
The Edrophonium/Tensilon test improves myasthenic crisis or cholinergic crisis?
myasthenic crisis, makes cholinergic crisis worse
What are signs of cholinergic crisis
SLUDGE
salivation, lacrimation, urination, defecation, gastrointestinal distress, and emesis
What drugs do MG patients typically develop a tolerance to?
Anticholinesterases
-1st line of treatment
-Pyridostigmine > neostigmine
lasts longer, less s/e
max dose 120mg q3hr
Surgical treatment for myasthenia gravis
Thymectomy - usually performed stage 2a or 2b
What immunotherapies are used for short term treatment of MG crisis?
Plasmapharesis , Immunoglobulin
Which drug mimics the effects of succinylcholine?
high dose remifentanil
Which joints are typically involved in OA?
Weight bearing/high use joints: knees, hips, shoulders. Can also occur in lower cervical and lumbar spine
Heberden nodes are
Associated with OA; are bony growths at the distal interphalangeal joints (fingertip joint)
Preoperative evaluation of a patient with OA includes
extent of ROM in affected joints and neck, baseline severity of pain, and pain management use (NSAIDS/opiods)
What is recommended treatment for OA?
PT and exercise, joint replacement surgery if limited function
pain relief- NSAIDS, heat, TENS, acupuncture
PRP, Stem cells, prolotherapy
What is recommended to avoid in OA?
corticosteroids
RA is an autoimmune disease that affects which joints
proximal interphalangeal and metacarpophalangeal joints
OA is ______ in the morning, and _______ throughout the day
better, worse
RA is _______ in the morning, and ______ throughout the day
worse, better
Unlike OA, RA typically has what at the joints?
Synovial inflammation, swelling, increased fluid
RA is more common in men or women?
2-3x higher in women
RA typically coincides with:
trauma, surgery, childbirth, or exposure to temperature extremes
Symmetrical distribution of several joints is characteristic of which disease?
RA; hands, wrists, knees, feet
Which joints are not affected by RA?
thoracic and lumbosacral spine
Atlantoaxial subluxation is associated with
RA
Subluxation of cervical vertebrae (other than atlantooccipital) can occur and cause
migraines, dizziness, vertigo, tinnitus, neck pain w/o movement
Atlantoaxial subluxation is ________
separation of the atlanto-odontoid articulation. >3mm distance between anterior arch of atlas and the odontoid process. Odontoid process protrudes into the foramen magnum and exerts pressure on the spinal cord or impairs vertebral artery blood flow
What are s/s of cricoarytenoid arthritis
Acute- hoarseness, pain on swallowing, dyspnea, stridor, swelling and redness seen via direct laryngoscopy
Chronic- asymptomatic or variable degrees of hoarseness
Treatment options for RA include
NSAIDs, corticosteroids, DMARDs (methotrexate), TNF inhibitors, IL-1 inhibitors, surgery
Anesthesia concerns for patients with RA include
- Neck ROM d/t atlantoaxial subloxation
- Jaw movement limitations d/t TMJ
- severe rheumatoid lung disease
- protect eyes
- may need stress dose steroids
Typical manifestations of Systemic Lupus Erythematosus
- Antinuclear antibodies
- Malar (butterfly) rash
- Discoid lesions- thick and disc shaped (often face or scalp)
- Thrombocytopenia
- Serositis
- Nephritis
Death during course of SLE may be due to _____
coronary atherosclerosis - coronary atherosclerosis development accelerated by treatment with steroids
Pulmonary concern in patient with SLE
- Vanishing lung (recurrent atelectasis, diaphramatic weakness or phrenic neuropathy)
upper airway obstruction s/t:
- Recurrent laryngeal nerve palsy
- cricoarytenoid arthritis
Common hematologic complications with SLE include
hemolytic anemia, thromboembolism, thrombocytopenia, leukopenia
Treatment for SLE includes
- NSAIDs or ASA
- Antimalarial - hydroxychloroquine, quinacrine
- Corticosteroids
- Immunosuppressants - methotrexate, azathioprine
Malignant Hyperthermia is linked to which genetic mutation
Ryanodine receptor RYR1 gene
Dihydropyridine receptor
Triggering agents for MH
- inhaled VAs
- succinylcholine
What is malignant hyperthermia
Hypermetabolic syndrome d/t sustained high levels of sarcoplasmic Ca2+ that rapidly drives skeletal muscle into a hypermetabolic state. Inabiity of Ca2+ pumps and transporters to reduce the unbound sarcoplasmic Ca2+ below the contractile threshold
Non-triggering MH agents
- Barbiturates
- Propofol
- etomidate
- benzos
- opioids
- droperidol
- nitrous oxide
- Nondepolarizing NMB
- Anticholinesterases
- Anticholinergics
- Sympathomimetics
- Local anesthetics
- A2 agonists
What are the early signs of MH
- hypercarbia and tachypnea *
- sinus tachycardia
- masseter muscle spasm (biting tube/high airway pressures)
- generalized muscle rigidity
- peaked T waves
- Metabolic and resp acidosis
What are the later signs of MH
- hyperthermia
- dark urine s/t rhabdo
- Elevated CPK
- VT/VF
- Acute renal failure
- cardiovascular collapse
- DIC
Treatment for MH includes
- D/c all triggering agents
- hyperventilate with 100% O2 @10 L/min
- Change breathing circuit and soda lime
- Dantrolene or Ryanodex
- bicarb (to treat acidosis)
- CaCl or calcium gluconate (to treat hyperkalemia)
- insulin + dextrose (treat hyperkalemia)
- Refrigerated IV solution (to cool patient)
Dantrolene vials contain how many mg, how should it be diluted?
20mg + 3mg mannitol; dilute with 60mL sterile water
Initial dose of dantrolene
2.5mg/kg
(total 10mg/k for the average sized patient)
MH registry
1-800-MH-HYPER (644-9737)
MH testing for pt and family members includes
muscle biopsy contracture testing
measuring contraction force of biopsy tissue when exposed to caffeine or halothane
