Musculoskeletal Diseases 2/18 Flashcards
Test 2
Scleroderma is know as _______
Systemic Sclerosis
What disorder is CREST used for? What does it mean?
Scleroderma
(C)alcinosis: calcium deposits on skin
(R)aynauds phenomenon
(E)sophageal dysfunction: acid reflux & decrease in motility
(S)clerodactyly =: skin thickening/tightening on hands/finger
(T)elangiectasias: dilation of capillaries –> red spots on face
What is Raynauld’s phenomenon triggered by? What are Tx?
Cold
-stress
-pain
-in adequate perfusion
Tx: keep extremities warm; treat pain; adequately profuse; digital block (last resort –> causes vasodilation)
What are the 3 interrelated processes that scleroderma are characterized by?
- Autoimmune-mediated inflammatory vasculitis.
- Tissue & internal organ fibrosis
- Organ sclerosis with vascular structures that do not regenerate.
Why is the prognosis for scleroderma poor?
Visceral/organ involvement (kidneys, lungs, heart, GI) and the vascular structures do not regenerate.
What are S/S for Scleroderma? Go through all systems.
Skin: Taunt, Ca deposits
MS: limited mobility, contractures (dt taunt skin), skeletal muscle myopathy –> difficulty moving
NS: distal nerve compression (ulnar/radial)
CV: systemic/pulm HTN; dysrhythmias; vasospasms, CHF, increase risk: pericarditis/pericardial effusion
Pulm: pulm fibrosis –> decreased compliance
Renal: decreased RBF & HTN; renal crisis precipitated by corticosteroids
GI: Reflux, malabsorption, coagulation disorders
What consideration should we have with induction for scleroderma? Why?
Use Etomidate
-Do slow induction
Why: reduces risk of pulm HTN
What are signs of pulmonary hypertension? Tx?
JVD
-increase R ventricle
CXR: pulm edema
Tx: keep on the dry side
How do we Tx Renal crisis? What causes it?
ACE inhibitors
Steroids
T/F: Reglan/metoclopramide works well in scleroderma
F
It does not work to increase motility
What is the Tx for Scleroderma?
PPI –> reflux
ACE-I –> renal crisis
CCB –> raynauds
PDE inhibitors –> Pulm HTN
Dig –> increase CO
Imm therapy/steroids
How do I Tx ACE-I/ARBs-induced hypotension in scleroderma?
Vasopressin
What do I need to make sure I get on pts with scleroderma? Why?
ECHO
risk of pulm HTN
What drug works in increasing motility in scleroderma?
octreotide
What are the anesthesia considerations we should have scleroderma?
Airway: Limited mandible motion; small mouth opening; limited neck, ROM; increase risk of oral bleeding
CV: if needing A-line w/ raynauds –> decrease flow distal to line
Pulm: avoid increasing PVR
GI: high risk aspiration –> PPIs/H2 antagonist/NGT/ OGT to decompress
VTE prophylaxis
Stress dose
In Scleroderma, what can we give for oral bleeding?
TXA
Vitamin K
Topical phenylephrine/epi
__________ maybe a better option with scleroderma
Regional anesthesia
What is the stress dose?
Hydrocortisone
100 mg q6-8h
What is the VTE prophylaxis dose?
Heparin
5000u SQ
DMD =
(Pseudohypertrophy muscular dystrophy) Duchenne Muscular Dystrophy
Duchenne Muscular Dystrophy starts in ___________ and is more common in ___________
childhood
men
By _______ yo, pt are not able to walk independently anymore with Duchenne Muscular Dystrophy
8-10 years old
Duchenne Muscular Dystrophy is characterized by what 2 things?
Muscle wasting
decreasing strength
What is the initial symptoms of Duchenne Muscular Dystrophy?
Frequent falls
impaired gait
diff climbing stairs
In Duchenne Muscular Dystrophy, pts wont live past early __________ and usually die from ___________ complications
adulthood (20-25 yo)
pulmonary (CHF/PNA)
What gene mutation is responsible for Duchenne Muscular Dystrophy? Where is it located?
Dystrophin gene on the X-chromosome
In Duchenne Muscular Dystrophy, _________ infltrations = ____________-
Fatty
Pseudohypertrophic
What are S/S of Duchenne Muscular Dystrophy?
CNS: intellectual disabilities
MS: kyphoscoliosis; skeletal muscle atrophy; serum CK 20-100x normal (dt muscle wasting) –> increased K
CV: sinus tach, cardiomyopathy, EKG abnormalities (increased K)
Pulm: we can respiratory muscles/cough; OSA; pulm HTN
GI: hypermotility; gastroparesis
What type of test should we get on Duchenne Muscular Dystrophy pts?
ECHO –> pulm HTN
EKG –> increased K from rhado dt muscle wasting
What type of EKG changes would you see in Duchenne Muscular Dystrophy?
Short PR interval
Sinus tach
V1: tall R waves
Limb leads: deep Q waves
What are the anesthesia considerations we should have with Duchenne Muscular Dystrophy?
Airway: weak laryngeal reflexes/cough –> don’t over sedate; hard to clear secretions
Pulm: weakend muscles –> may want to avoid NMB
CV: EKG/ECHO
GI: delayed gastric emptying
What medications do we use for reversal in Duchenne Muscular Dystrophy?
Sugammadex
Not neostigmine or glycopyrrolate
What consideration should we have w/ Duchenne Muscular Dystrophy if we have to put them on the ventilator?
Have to be on the ventilator longer up to 36 hrs post Sx –> have to go to ICU
Does your facility have an ICU? –> may need to transfer our before or after procedure depending on the severity/emergency of the case
In Duchenne Muscular Dystrophy we want to avoid what NMB? Why?
Succs
increased K from muscle wasting; this will increase K even more.
With Duchenne Muscular Dystrophy, there’s an increased risk of _______.
MH
In Duchenne Muscular Dystrophy, which type of anesthesia is preferred?
Regional
In pediatrics with Duchenne Muscular Dystrophy, what are 2 good drugs for sedation?
Ketamine
Precedex
What is Myasthenia Gravis characterized by?
Cycles of exacerbation and remission
What is Myasthenia Gravis?
Decreased functional post-synaptic Ach-R at the NMJ from antibodies –> muscle weakness w/ rapid exhaustion w/ basic activity
Myasthenia Gravis is usually developed when?
later in adulthood
Myasthenia Gravis ALSO results in ________ abnormalities
thymus
Exhaustion from Myasthenia Gravis is _________ recovered with rest
partially
Pts with Myasthenia Gravis are sensitive to ______ and we should try not to use them.
NMB
What unit is destroyed on the Ach-R with Myasthenia Gravis?
Post synaptic Alpha-subunit
______% of receptors can be lost in Myasthenia Gravis
80
What are the Muscle-specific kinase (MuSK) antibodies in Myasthenia Gravis? What percentage of people w/ Myasthenia Gravis have this?
Tyrosine kinase antibody that is cruicial in the maintenance of NMJ and have no thymus involvement
10%
What is the difference between the types of Myasthenia Gravis?
Type 1: limited to ocular involvement
Type2a/2b
Type3
Type4: severe form of skeletal muscle weakness
What are S/S of Myasthenia Gravis?
-Ptosis (eye drooping); diplopia (double vision); dysphagia
-dysarthria (diff speaking); diff handling savila
-isolated resp failure
-arm, leg, trunk muscle weakness
-increase risk myocarditis
-autoimmune associated risk (including pernicious anemia/hyperthyroid)
What may be the only symptom in Myasthenia Gravis?
Isolated respiratory failure
What type of antibiotics should you avoid in Myasthenia Gravis? Why?
Mycin ABx (Gentamicin, streptomycin, tobramycin)
inhibit Ach release at NMJ –> severe respiratory muscle weakness
What causes Myasthenia crisis vs Cholinergic crisis? What are the different s/s?
MG crisis
cause: drug resistance/tolerance; missed dose
s/s: severe muscle weakness;resp failure
Cholinergic crisis
cause: excess anticholinerergics
s/s: SLUDGEM
What are drugs that can causes cholinergic crisis?
Atropine
Scope patch
Hydroxzine
Benadryl
Phenergan
glycopyrrolate
SLUDGEM =
Salivation
Lacrimation
Urination
Diarrhea
Gastrointestinal
Emesis
Miosis (Pupil constriction)
What is the relevance of the Tensilon Test? What does it consist of?
Give 1-2mg IV of Edrophonium
Better –> MG crisis
Worse –> Cholinergic crisis
What is the Tx for Myasthenia Gravis?
Anticholinesterases: Pyridostigmine > neostigmine
Thymectomy: Reduces Ach-R antibodies thru unknown MOA
–induces remission
–reduces use of immunosuppressants
–full benefits delayed after Sx
–invasise bc thymus next to heart
Immunosuppressants: corticosteroids, azathioprine, cyclosporine, mycophenolate
Immunotherapy (crisis):
–plasmapheresis
–immunoglobulin
What considerations should we have with MG and -stigmine?
Used in Tx so may have tolerance –> decrease effectiveness when using for reversal –> just dont use NMB bc too much of a risk with already muscle weakness and then possible no reversal.
What is the dose for -stigmines in Myasthenia Gravis?
120mg q3H
higher doses –> cholinergic crisis
In Myasthenia Gravis, pts are resistant to ____________. What is a good alternative? Why?
Succs
Remifentanil
similar effects to succ w/o depolarization
-can use if need to quickly get an airway and cant use succs
What are anesthesia management considerations for MG?
Aspiration risk
-weakend pulmonary effort
-mark sensitivity to nondepolarizing muscle relaxant
-resistance to succs
-intubate without NMBD
With Myasthenia Gravis, you should use ________ to decrease risk for aspiration
Reglan/metoclopramide
H2 antagonists
What joints are Osteoarthritis common in?
Knee
Hip
Shoulder
hands
What causes Osteoarthritis?
Repetitive bio mechanical stress
esp. w/ heavy loads
What is Osteoarthritis?
Chronic degenerative process affecting articular cartilage
What type of cartilage does Osteoarthritis affect?
Articular cartilage
Inflammation with osteoarthritis should be ________
Minimal
if big/very swollen –> something else wrong (maybe infection)
What is another big contributor of osteoarthritis?
Obesity
In osteoarthritis, pain is present with _________ and relieved by_________
Motion
Rest
What are Heberden nodes?
Seen in Osteoarthritis
In the distal interphalangeal joints (hands/fingers)
Disc/joints sticking out
Describe degenerative disease in Osteoarthritis in reference to vertebral bodies & intervetebral discs
Lean forward –> pressure on disc –> disc protrudes –> pressure on nerves –> pain/pain shots down leg
arc back –> pressure on facets joints –> compression of dorsal nerve roots –> pain
What is the most common area for degenerative disease pain with Osteoarthritis in the back to be?
Mid-lower lumbar
C6-C7
What is the recommended Tx for Osteoarthritis?
PT/exercise –> maintain muscle function
NSAIDs
Acupuncture
Stem cell
Joint replacement Sx
We do NOT want to give _______ with Osteoarthritis. Why?
corticosteroids
It will help temporarily –> then get worse
What are anesthesia management considerations we should have with Osteoarthritis?
Limited ROM with neck and possibly other extremities
RA =
Rheumatoid Arthritis
What is RA?
Autoimmune-mediated systemic inflammatory disease that causes pain
Where does RA normally affect?
Proximal interphalangeal (hands) and metacarpophalangeal joints (feet)
What is a consideration for any pt that is on an immunosuppressant?
Make sure they have their vaccines!
Pts with RA are normally ______ than pt with osteoarthritis.
younger
RA is more common with _______ joints
multiple
What are S/S of RA?
-Atlantoaxial subluxation
-Cricoarytenoid arthritis
-osteoporosis
NM: weakened skeletal muscles–> peripheral neuropathy
CV: Increase risk pericarditis, accelerated coronary atherosclerosis
Pulm: restrictive lung changes
Blood: anemia, neutropenia, elevated platelets
-Keratoconjunctivitis sicca and xerostomia
RA is worse in the __________
morning
gets better through the day
What is a main difference in RA and osteoarthritis?
RA: worse in the morning –> better thru day
Osteo: worse thru the day
Where is RA rarely seen in the back? where is it more commonly seen?
Rare: lumbar/thoracic
common: cervical
In RA, how do we decrease swelling in the TMJ?
therapy
Wont drain dt increase risk of infection
What is Atlantoaxial subluxation? What disorders is this seen in?
Odontoid process protrudes into the foramen magnum –> cord/art compression –> stroke s/s
RA
Downs syndrome
What is the difference between acute and chronic Cricoarytenoid arthritis in RA? What considerations should I have with this?
Acute: hoarseness; dyspnea; stridor; front neck tenderness/pain over larynx; swelling/redness over arytenoids –> high risk of vocal cord, injury, or loss of airway after extubation
Chronic: asymptomatic or variable degree of hoarseness; dyspnea; upper airway obstruction
T/F: In RA, Subluxation of other cervical vertebrae can occur.
T
Causes migraines, dizziness, vertigo, tinnitus, ringing in the ears, neck, pain without movement
What is RA vasculitis?
antigen antibody complex–> blood vessels inflammed –> organ/tissue damage
How does RA present?
Sinlge/multiple joints
-painful synovial inflammation –> can be drained
-morning stiffness
-symmetrical distribution of several joints
-furisform swelling
-synovitis temporomandibular joint (TMJ) –> swelling in TMJ but won’t drain dt increase risk of infection –> therapy to increase lymphatics to decrease inflammation
What are Rheumatoid nodules?
Nodules that develope with RA in the lunds that resemble TB or cancer on CXR
can occlude alveoli on bronchi when bigger
Sjogren Syndrom (Keratoconjunctivitis sicca and xerostomia) is associated with ________
RA
In RA, you have a ________ in clotting.
increase in clotting
What is the Tx of RA?
NSAIDs –> decrease joint swelling/pain
Corticosteroids –> decreased joint swelling/ pain/ morning stiffness
DMARDs (disease-modifying antirheumatic drugs): Methotrexate: lots of SE
Tumor necrosis factor (TNF-alpha) inhibitors: lots of SE
Interleukin (IL-1) inhibitors: slower onset/ less effective; work better than Methotrexate
Surgery
What is the DMARDs we give for RA?
Methotrexate
What are anesthesia management considerations for RA?
Airway: Atlantoaxial subluxation, TMJ limitation, cricoarytenoid joint –> use Videolaryngoscopy –> dont need to extend neck as much
-severe rheumatoid lung disease
-protect eyes
-stress dose
SLE =
Systemic lupus Erythematosus
Who is Lupus more common in?
African-American females age 15 to 40
What is lupus?
Multisystem chronic inflammatory caused by anti-nuclear antibody production
What is the main presentation of Lupus?
Malar (butterfly) rash
What causes drug induced lupus?
Slow acetylators:
Isoniazid
D-Penacillamine
Alpha-methyldopa
Increase risk of drug induced lupus dt slow metabolism of drugs
Lupus is difficult to manage in __________-
pregancy
What are s/s of lupus?
Polyarthritis/dermatitis
-symmetrical arthritis
-Increase risk avascular necrosis of femoral head or condyle
CNS: Cognitive/Psych changes
CV: Pericarditis, CAD, Raynauds
Pulm: Lupus PNA; restrictive lung disease; vanishing lung syndrome
Renal: Glumerulonephritis, decreased GFR
GI: Abd pain
Liver: pancreatitis, elevated liver enzymes
NM: skeletal muscle weakness
Blood: thromboembolism, thrombocytopenia, hemolytic anemia
Skin: malar rash, discoid lesions, alopecia
Does Lupus usually have spinal involvement? What affect does this have?
No spinal involvement –> no airway involvement
Which MSD has increased risk of avascular necrosis?
Lupus
In lupus, what are the cog/psych changes dt?
Mostly insecurities regarding skin presentation
What is vanishing lung syndrome? What MSD is this associated with?
Diaphragm moving up into chest –> lung disappears
Lupus
How does lupus and pneumonia present? What consideration should I have with this?
Pulmonary infiltrates –> pleural effusions –> nonproductive cough –> severe difficulty breathing
Be cautious w/ lupus presenting with pulm s/s dt this & restrictive lung disease component
What are s/s a pericarditis?
CP
Friction rub
ST elevation in all leads
Pericardial effusion
Death during Lupus may be dt _________ and is accelerated by Tx of Lupus with _________
Coronary atherosclerosis
corticosteroids
Lupus is associated with _______ anemia
hemolytic
Which NMD has the least effect on skeletal muscle weakness?
Lupus
What are discoid lesions? What do you see them in?
Thick disc shaped lesion; red/scaly; mostly seen on scalp/face –> causes permanent scarring; NOT itchy/painful
With lupus you’ll see __________ in areas exposed to sunlight. What does this look like?
erythematous rash
Measles
What is the Tx for Lupus?
NSAIDs
ASA
Antimalarial: Hydroxychloroquine; quinacrine
Steroids
Immunosuppressants: Methotrexate; azathioprine
For Lupus, ____________ is better than high dose steroids
Immunosuppressants
What is the anesthesia management considerations for lupus?
Airway: recurrent laryngeal nerve palsy; cricoarytenoid arthritis –> use videolayrngoscpoe
Stress dose
What gene is mutated in MH? What is this in?
RYR1 gene
Ryanodine receptor & Dihydropyridine receptor
What is MH?
Hypermetabolic syndrome characterized by uncontrolled elevation in sarcoplasmic Ca++ –> sustained muscle contractions/rigidity –> rhabdomyolysis
MH has a _____% mortality rate
50
What causes MH?
exposure to volatile anesthetics and succs
If the pt is intubated, what is a main concern with MH?
biting down on ET tube and cutting off O2 flow
T/F: MH only happens periop
F
Can happen many hours postop
________ increases the risk of MH
family Hx
What are the non-triggering agents “safe drugs” for MH?
Barbiturates
Propofol
Etomidate
Benzos
Opioids
Droperidol
Nitrous oxide
Nondepolarizing muscle relaxant
Anticholinesterases
Anticholinergics
Sympathomimetics
Local anesthetics
Alpha-2 agonist (precedex, clonidine)
What are the early s/s of MH?
Hypercarbia
Tachypnea
Sinus tach
Masseter muscle spasm
General muscular rigidity
Peak T waves
Metabolic/respiratory acidosis
What are the late s/s of MH?
Hyperthermia
Coca-Cola urine –> rhabdo
Elevated CPK
Cardiac arrhythmias –> VT/VF
ARF –> CRRT
Cardiovascular collapse
DIC
What is Masseter Spasm?
When succs is used –> spasms of muscles responsible for chewing
What is Tx for MH?
CALL FOR HELP
-D/C all triggering agents
-Dantrolene
-Disconnect from machine –> Bag with hand 100% O2
-Get a new anesthesia machine –> hook pt up
——-Old machine needs to be completely cleaned out. vaporizers taken off; flushed with O2 for 15-20 mins; Changed breathing circuit & soda lime
-Give large amounts of crystalloids –> flush kidneys
-Bicarb –> acidosis/increased K
-Ca++ –> increased K
-Insulin & glucose –> increased K
-COOL THE PT ANY WAY POSSIBLE
-treat arrhythmia
-monitor UO
What is the dose for dantrolene? How do you reconstitute dantrolene?
Dose
Initial: 2.5 mg/kg
max: 10 mg/kg
Reconstitute: 20mg dantrolene + 3 g mannitol in 60 cc sterile water
How long should MH pt be expected to stay in ICU?
24-48 hours
How do you test for MH?
Muscle biopsy contracture test:
biopsy –> expose to halothane & caffeine –> measures contraction
