Musculoskeletal assessment Flashcards
Exam 2 content
In what condition does Reglan not work to improve motility? What would you give instead?
Scleroderma. Somatostatin analogues (Octreotide)
What can too much oxygenation cause?
Vasoconstriction
What complication tends to kill DMD (Duchenne’s) patients?
Weakness/failure of the diaphragm leading to pulmonary complications
What disease commonly presents with ptosis? If this is the only symptom the patient is experiencing what Type is this?
Myasthenia Gravis. Type I.
ACh-esterase inhibitor of choice in MG?
Pyridostigmine
Which condition is resistant to Succ? What can you give instead
Myasthenia Gravis. Remifentanil.
What condition has Heberden nodes, what are these?
Osteoarthritis. Distal interphalangeal reddened nodes on knuckles.
Easy way to distinguish OA from RA?
OA = distal phalanges are the problem (swollen, nodes)
RA = proximal phalanges are the problem (swollen, nodes). Pain and stiffness in the morning. TMJ pain.
What condition has cricoarytenoid arthritis and atlantoaxial subluxation?
RA (and Down’s syndrome)
In what condition is the arthritis symmetric?
Lupus
What is vanishing lung syndrome?
There is a mediastinal shift to the affected lung and the diaphragm shifts upward (the opposite movement occurs in a pneumo, mediastinum shifts away from the affected lung and diaphragm drops)
What condition can have vanishing lung?
Lupus
What condition of the ones we discussed in class is most prone to thrombo-embolic events?
Lupus
What conditions can have cricoarytenoid arthritis?
Lupus and RA
What 2 medications can be given to treat MH? What is the main difference b/w the two?
Dantrolene and Ryanodex. You need to mix 20-30 vials of Dantrolene if you need it! Ryanodex is much more $$, but much easier and quicker to administer.
What can cause MH?
Volatiles (sevo, iso, des) and Succ
What drug can cause masseter spasms?
Etomidate
Dose range for dantrolene?
2.5 mg/kg 10 mg/kg max
2 issues with cooling a patients during/after MH?
Shivering and electrolyte disturbances
What drugs could help with shivering?
Demerol, propofol, A2 agonists (clonidine, precedex) NMBDs (not sux) such as cisatracurium
What are the 3 hallmarks of scleroderma?
Auto-immune mediated vasculitis, fibrosis of skin and internal organs via collagen deposits, and microvascular changes causing fibrosis and sclerosis
Define CREST and what disease process does it help identify?
Scleroderma
C = calcinosis
R = Raynauds
E = esophageal dysfunction
S = Sclerodactyly (thick/tight skin on hands)
T = Telangiectasias (dilation of capillaries causing red marks)
What is the only drug that has been shown to slow the progression of renal disease in scleroderma?
ACE inhibitors
What is the cause of DMD?
Mutation of the dystrophin gene
What drugs do you need to avoid giving to DMD patients?
Sux is the big one, but technically all NMBDs
What anesthesia is preferable for DMD patients?
Regional over GA
What are some unique processes to DMD?
Kyphoscoliosis, serum CK 20 - 100x normal, waddling gait
What is the hallmark pathology of MG?
Lose and decreased function of post-synaptic ACh receptors
Rapid exhaustion of voluntary muscles with repetitive use that partially recovers at rest would make you suspect what condition?
MG
List the types of MG
I = only ocular muscles affected
IIa = slowly progressive and mild, spares respiratory muscles (responds well to drug therapy)
IIb = rapidly progressive more severe form that can involve respiratory muscles (does not respond well to drug therapy)
III = Acute onset and rapid deterioration within 6 months (high mortality)
IV = Severe form of weakness, progression from types I or II
What would an edrophonium/tensilon test do if you were in a myasthenic crisis vs cholinergic crisis?
MC = improves s/sx
CC = makes s/sx worse
Myasthenic crisis vs cholinergic crisis?
MC = severe muscle weakness and respiratory failure
CC = SLUDGE-M, profound muscle weakness, bradycardia, diarrhea abd pain
What procedure is commonly done to help improve s/sx and reduce need for immunosuppression in MG?
A thymectomy - full benefits do take time to manifest
Why are MG patients notorious for being resistant to sux?
They have very few ACh receptors left so there are far less receptors for sux to bind to
Assuming you give a large enough dose to produce an effect, why is sux’s effect profoundly longer in MG patients?
They are common on pyridostigmine which inhibits plasma cholinesterase, meaning there are less esterases around to break down sux/force it to leave the receptor
Why are MG patients extremely sensitive to non-depolarizing muscle relaxers?
Because they have so few ACh receptors it doesn’t take much drug to block them
What treatment is recommended and what should you avoid in OA treatment?
PT and exercise, avoid corticosteroids (may improve s/sx but the further degrade the joint)
Why are we concerned about atlantoaxial subluxation?
Because the odontoid process can press on the spinal cord, or cause a stroke by occluding the vertebral arteries
What drugs could help with RA?
Cox 1/2, corticosteroids, DMARDS (methotrexate), TNF and IL-1 inhibitors
What is advantageous about TNF (tumor necrosis factor) drugs over DMARDs in RA?
TNF has a faster onset
What condition commonly has avascular necrosis of the femoral head?
Lupus
What GI/liver issues are common with lupus?
pancreatitis and elevated liver enzymes
What condition can anti-malarial agents help treat?
Lupus
What is the root cause of MH?
Genetic mutation of the ryanodine receptor
What is a massester spasm? What causes it? Why is it important?
Jaws of steel (jaws rigid, won’t open)! Sux administration. It can be an early indicator of MH
What are are some early signs of MH? Is hyperthermia an early or late sign?
ETCO2 increase, tachycardia, muscular rigidity, acidosis. Hyperthermia is a late sign
Describe basic treatment for MH
Stop all triggering drugs/gasses, bag patient until a new vent comes, hyperventilate at 100%, change breathing circuit, try to cool the patient and give dantrolene/Ryanodex
What area does the trachea encompass?
from the inferior cricoid to the carina. 10-15 cm in the average adult.
On US when looking at the neck how can you identify cricoid cartilage and the trachea?
The cricoid is a complete ring. The trachea has C shaped cartilage rings.
How do you measure the thyromental distance?
how many finger breadths between tip of chin to thyroid notch–> goal of at least 3 finger breadths
What is back up-head elevated intubation?
can use this method with any patient that is struggling to breathe while awake intubating.
How can you use the ventilator to help pre-oxygenate the patient?
Vapox (ventilator assisted pre-oxygenation)
Go to SIMV or PSV mode
Put NC on and mask from ventilator, turn flow rate up and increase FiO2. Turn PEEP to 5 and increase pressure support to 5-10 cmH2O
what is scleroderma?
an autoimmune disorder characterized by inflammatory vasculitis, fibrosis of the skin from deposition of extracellular collagen, and tissue and organ sclerosis
What acronym is used for memorizing symptoms of scleroderma?
C- calcium deposits in the skin
R- Raynaud’s phenomenon
E- esophageal dysfunction like acid reflux and decreased motility
S- sclerodactyly- thickening and tightening of skin on the hands
T- telangiectasias- dilation of capillaries causing red marks on the skin
what are the typical treatments for scleroderma?
PPI’s for acid reflux. CCB’s for Raynaud’s.
What are some anesthesia concerns for patients with muscular dystrophy?
Avoid Succinylcholine.
Weak cough, will likely need to remain intubated in PACU.
Increased risk for MH (may decided to do TIVA to avoid this)
How can you test to differentiate a myasthenia crisis versus a cholinergic crisis?
give 1-2mg of Edrophonium IVP (the Tensilon test). If the patient improves–> myasthenic crisis. If it gets worse–> cholinergic crisis
What are some anesthesia concerns with MG?
aspiration risk. Patient will take longer to wean off the vent. Very sensitive to NMBD, intubate w/o these if possible.
What are some of the most worrisome S/s of patient’s with RA for anesthesia?
- Atlantoaxial subluxation- difficulty positioning neck for intubation. Increased pressure on vertebral arteries can cause stroke like symptoms.
- Cricoarytenoid arthritis- swelling of arytenoids- difficulty passing ETT. Worsened hoarseness, dyspnea and stridor after extubating.
- TMJ limitation with jaw thrusting.
What are some S/s of SLE?
- malar rash “butterfly rash”
- thrombocytopenia
- serositis (inflammation of serous tissues like the tissue lining the lungs)
- nephritis
What specific type of anemia presents with Lupus? What about with the other autoimmune disorders discussed?
hemolytic anemia. Pernicious anemia or dilutional anemia.
What are the earlier S/s of MH?
- hypercarbia (ETCO2 increases markedly)
- Tachycardia (tachypnic if breathing spont)
- Masseter muscle spasm
- general muscle rigidity
- peaked T waves
- acidosis
What are the later S/s of MH?
- hyperthermia
- rhabdomyolysis
- cardiovascular collapse
- DIC
Horner’s syndrome is the result of blockade of what?
Stellate Ganglion
