Musculoskeletal Diseases (Exam II) Flashcards
1
Q
What is the pathophysiology of scleroderma?
What is the other name for it?
A
- Autoimmune disease
- w/ progressive tissue fibrosis/sclerosis and
- vascular injury.
- Systemic Sclerosis
2
Q
What mnemonic guides the main symptoms associated with scleroderma?
Expound on the mnemonic.
A
- Calcinosis - calcium deposits in the skin
- Raynaud’s - triggered by cold or stress
- Esophageal reflux
- Sclerodactyly
- Telangiectasia’s - dilation of caps causing red marks on the skin
3
Q
What skin and musculoskeletal abnormalities might be seen with scleroderma?
A
- Taut skin
- Contractures & myopathy
increased risk for pressure injuries
4
Q
What can happen to nerves with scleroderma?
A
Compression
5
Q
What does xerostomia mean?
A
Dry mouth
6
Q
What treatments are used for scleroderma?
A
- Symptoms alleviation
- ACE-inhibitors
- Digoxin
- Steroids
7
Q
If hypotension issues with scleroderma pt on ACE Inh., what is drug of choice in OR?
A
Vassopressin
8
Q
What is the one treatment for scleroderma that has been shown to ______ and to treat _____ ?
A
Alter the course of scleroderma
sclerodermal renal crisis
ACE Inhibitors
9
Q
How many scleroderma pts develop renal crisis?
A
10-15%
10
Q
What airway and pulmonary considerations exists for scleroderma?
A
- Pulmonary fibrosis (↓ compliance)
- Decreased ROM for airway
11
Q
What CV considerations exists for scleroderma? (6)
A
- PulmHTN
- Dysrhythmias
- Small artery vasospasm’s
- CHF (RV enlarged, JVD?)
- pericarditis
- pericardial effusion
12
Q
What would the induction drug of choice be for Scleroderma pt?
A
Etomidate
- great for CV unstable pts
13
Q
What GI symptoms exist for scleroderma?
A
- Xerostomia
- GI tract fibrosis
- Poor dentition
- GERD
14
Q
What dose of metoclopramide would be utilized for GI tract fibrosis from scleroderma?
A
Trick question. Metoclopramide would not work in this scenario.
15
Q
Scleroderma anesthesia management
Airway:
CV:
GI:
A
Airway: Mandibular motion
small mouth opening
neck ROM
oral bleeding
CV: IV/arterial line access
GI: Aspiration
16
Q
Scleroderma anesthesia management
Pulmonary:
Eyes:
A
Pulm: Decreased pulmonary compliance and reserve, avoid increasing PVR
Eyes: corneal abrasions
17
Q
Scleroderma anesthesia management
Last 5 considerations
A
- Consider Regional anesthesia
- Keep warm
- VTE prophylaxis
- Positioning
- Pulse Ox difficulties
18
Q
What is Duchenne’s Muscular Dystrophy (DMD)?
What initial symptoms are present at 2-5 years of age?
A
- X-linked dystrophin disorder resulting in muscle atrophy.
- (Ages 2-5) = waddling gait
- frequent falling
- can’t climb stairs
- Gower’s sign
- need for walker
19
Q
It is a good idea to get an echo in what pt population?
A
Those with DMD
20
Q
What is the protein that plays a large role in stabilization of the muscle membrane?
A
Dystrophin
21
Q
DMD pts usually only live to be ____ and die from _____ or ____
A
20-25 yrs old; pulmonary; CV complications
22
Q
What s/s are seen with DMD?
List:
CNS
Musculoskeletal
A
- CNS - intellectual disability
- MS - Kyphoscoliosis, muscle atrophy, ↑ CK (20-100x normal)
23
Q
What s/s are seen with DMD?
CV:
Pulm:
GI:
A
- CV - ↑ HR, cardiomyopathy, short PR, tall R-wave, deep Q-wave
- Pulm - weakened respiratory muscles and weak cough, OSA
- GI - hypomotility & gastroparesis
24
Q
What are the anesthetic concerns and interventions relevant to DMD patients?
- Airway
- Pulmonary
- CV
- GI
A
- Airway - weak laryngeal reflexes & cough
- Pulm - weakened muscles
- CV - Get pre-op EKG & echo
- GI - delayed gastric emptying
caution with NMBs, use suggamedex
25
What drug should be avoided with DMD patients?
- Succinylcholine (Rhabdo & ↑K⁺)
*use NDMBs*
26
What type of anesthesia is prefereable for a DMD patient?
**Regional** (vs GA)
27
Why might one use less volatile gasses with DMD patients?
- DMD patients have ↑risk of malignant hyperthermia.
*Ensure you have Dantrolene*
| Use TIVA instead of volitiles
28
What are the top 2 choices of anesthetic to use for DMD pts?
1. **Ketamine**
2. Dex
29
What is the pathophysiology of myasthenia gravis?
- ↓ function of NMJ post-synaptic ACh receptors.
*αlpha sub-units of ACh receptor are bound by antibodies.* - 80% of receptors can be lost
| Avoid NMBs if possible
30
What are the main classifications of myasthenia gravis that he mentioned?
Type I - limited to involvement of the extraocular muscles
Type IV - Severe form of skeletal muscle weakness
31
What organ is linked with the production of anti-ACh antibodies?
- Thymus
32
Which condition is characterized by partial recovery with rest?
Myasthenia Gravis
33
What test is used to diagnose myasthenia gravis?
Edrophonium/Tensilon Test
- 1-2 mg IVP
- Myasthenia symptoms improve with injection = (+) test
Cholinergic symptoms worsen = (-) test
34
What signs/symptoms might be seen with myasthenia gravis?
- Ptosis & diplopia
- Dysphagia & dysarthria
- Muscle weakness
- Myocarditis
35
Differentiate Myasthenic Crisis and Cholinergic Crisis.
- **Myasthenic Crisis** - Insufficient drug therapy and resulting respiratory failure.
- **Cholinergic Crisis** - too much -stigmine drug = SLUDGE-M symptoms.
36
What drugs are the firstline treatment for Myasthenia Gravis?
What would be done if drugs were ineffective?
- **Pyridostigmine** (AChesterase inhibitors) or Neostigmine
- Surgical Thymectomy
| tolerance to Neostigmine could present issue with reversal of NMBs
37
What drugs/treatments other than pyridostigmine or surgery could be used for myasthenia gravis? (6)
- Corticosteroids
- Azathioprine
- Cyclosporine
- Mycophenolate
- Plasmapheresis
- Immunoglobulin - Temporary effect
38
What anesthetic considerations exist for myasthenia gravis?
- Aspiration risk & weakened respiratory muscles.
- Sensitivity to NMBs (intubate without if possible)
- **No succinylcholine** (resistant to it)
- Use Remifentanil instead of Succs
39
Which medication can give similar results to succinylcholine when given in high doses?
Remifentanil
40
What is osteoarthritis (OA)?
What makes the pain better?
What joints is it most commonly seen in?
- Degeneration of articular cartilage with minimal inflammation.
- Pain **better at rest**.
- Pain is **worse with motion**.
| Most commonly seen in knees, hips, and shoulders
41
Obese pts with OA will need to ____ before Sx
lose weight
42
What are Heberden nodes?
What disease process do they indicate?
- Bony swellings of the distal interphalangeal joints.
- Osteoarthritis
- conginital joint disease
43
What spinal complications occur from osteoarthritis?
- Vertebral degeneration
- Nucleus pulposus herniation
- Nerve root compression
44
What are the treatments for osteoarthritis? (7)
- **PT & exercise**
- Maintenance of muscle function
- Pain relief (not opioids, heat, NSAIDS instead)
- Joint replacement surgery
- Platelet rich plasma
- STEM cells
45
Are osteoarthritis or rheumatoid arthritis patients prescribed corticosteroids?
- RA patients (**no steroids** for OA)
46
What anesthetic considerations exist for OA?
- Airway
- Limited ROM
47
What is rheumatoid arthritis?
What hand condition is often seen on inspection?
- Auto-immune systemic inflammatory disease
- Swelling of the **Proximal** Interphalangeal, metocarpophalangeal, and elbow joints.
48
RA pts are often taking ____ that make them a much higher risk for ____
steroids; viurses
49
What joints are usually spared by rheumatoid arthritis?
- Thoracic & Lumbosacral spine
50
What disease commonly has morning stiffness and fusiform swelling?
Rheumatoid Arthritis
51
With this condition it is common to have synovitis of the temporomandibular joint.
Rheumatoid Arthritis
52
Why would the sniffing position and thus intubation be affected in a patient who has rheumatoid arthritis?
- **Atlantoaxial subluxation** (pushes on spinal cord)
- Cricoarytenoid arthritis (hoarseness, dyspnea, and upper airway obstruction may be present)
53
Atlantoaxial subluxation is commonly found with these conditions
RA
Down syndrome
54
What cardiac symptoms can be seen with RA?
Pulmonary?
- Pericarditis and accelerated CAD
- Restrictive lung changes
55
What two facial symptoms are often seen with RA?
- Keratoconjunctivitis sicca (dry eye)
- Xerostomia (dry mouth)
56
What drugs are used to treat rheumatoid arthritis?
- NSAIDs
- Corticosteroids
- **DMARDs** (**methotrexate**)
- TNF-α inhibitors & Interleukin-1 inhibitors
57
Compare and contrast DMARDs vs TNF-α inhibitors & Interleukin-1 inhibitors in how they treat rheumatoid arthritis.
- DMARDs (methotrexate) slow disease progression but can take 2-6 months to see effects
- TNF-α & IL1 inhibitors generally work better than DMARDs (IL1's are slow than TNF)
58
What anesthesia considerations exist for rheumatoid arthritis? (4)
- Airway complications by atlantoaxial subluxation or TMJ.
- Severe RA lung disease
- protect eyes
- Stress dose steroids may be necessary
59
What is a malar rash?
What pathology is it characteristic of?
- Butterfly rash across the bridge of the nose and cheeks that is present with SLE.
60
What pt population is common with SLE? (Lupus)
Black females ages 15-40
61
Manifestations of SLE (5)
- Antinuclear antibodies
- Malar rash
- Thrombocytopenia
- Serositis
- Nephritis
62
What pathology is this and what are these lesions called?
- Discoid lesions characteristic of SLE.
- Thick and disc shaped
63
What type of rash is depicted below? What pathology is it characteristic of?
What often causes it?
- Maculopapular rash characteristic of SLE and exposure to the sun.
64
What CV signs are seen with SLE?
- **Pericarditis**
- CAD
- Raynaud's
65
SLE S/S
Hematology: (3)
GI/Liver: (3)
Hematology: Thromboembolism, thrombocytopenia, **Hemolytic anemia**
GI/Liver: ABD pain, pancreatitis, elevated liver enzymes
66
What type of arthritis is seen with SLE?
- Symmetrical w/ no spinal involvement but frequent breakdown of femoral head. (Avascular necrosis)
67
What pulmonary symptoms are characteristic of SLE?
- Lupus pneumonia
- Vanishing Lung syndrome (diaphragm has moved up into chest)
- Restrictive lung disease
68
SLE is commonly seen in this group of ppl
Common in young women and African Americans; ages 15 to 40
69
What drugs are utilized to treat SLE? (4)
- NSAIDs or ASA
- Antimalarials (HCQ & quinacrine)
- Corticosteroids
- Immunosuppressants (azathioprine & methotrexate)
70
What anesthesia considerations exist for SLE patients? (3)
- Recurrent laryngeal nerve palsy
- Cricoarytenoid arthritis
- Stress dose steroids likely necessary
71
What condition often has recurrent laryngeal nerve paralysis?
Lupus (SLE)
72
What are the early signs of malignant hyperthermia? (7)
- ↑CO₂
- ↑HR
- ↑RR
- Masseter muscle spasm (jaw spasms)
- Peaked T waves
- Acidosis
- Muscle rigidity
73
What is the mortality rate with MH?
50%
74
What gasses are safe and which are not for MH?
Des, Sevo, Iso not safe
Nitrous is safe
75
What condition results in uncontrolled elevation of sarcoplasmic calcium?
Malignant Hyperthermia
76
What are the late signs of malignant hyperthermia? (6)
- Hyperthermia
- Rhabdo & cola-urine
- ↑CPK
- Acute renal failure
- DIC
- VTach/Vfib
77
MH treatment (not drug)
D/C all triggering gasses or drugs
change breathing circuit and soda lime
Hyperventilate with 100% O2 at 10 L/min
Monitor urine output
78
What is initial Dantrolene dosing?
What is the max dose?
- Initial: 2.5mg/kg.
- Max: 10mg/kg
79
How is MH testing done?
- Muscle biopsy and halothane + caffeine contracture test.
80
Which of the following **best** characterizes myasthenia gravis?
A. Delayed Muscle Relaxation.
B. Fatiguability of skeletal muscle with repetitive use.
C. Rigidity after exposure to volatile anesthetics.
D. Muscle weakness that improves with repeated effort.
B. Fatiguability of skeletal muscle with repetitive use.
81
What are treatments indicated for a patient with rheumatoid arthritis?
A. Immunoglobulin injections and DMARDS.
B. Plasmapheresis and thymectomy.
C. Corticosteroids and DMARDS.
D. Alternating heat and cold therapies.
C. Corticosteroids & DMARDs
82
Signs and symptoms of scleroderma include: (select 2)
A. Small bowel hypomotility
B. Decreased pulmonary compliance
C. Diffuse pitting edema
D. Diarrhea
A. Small bowel hypomotility
B. Decreased pulmonary compliance
83
Which anesthetic plan is ideal for a patient with systemic lupus erythematosus?
A. Avoid the use of volatile anesthetics
B. Prepare patient for possible post-operative ventilator use.
C. Administer metoclopramide
D. Order a pre-operative CBC & ECG.
D. Order a pre-operative CBC & ECG.
*This is a dumb question*
84
Preoperative findings of Duchenne muscular dystrophy include:
A. Decreased serum creatine kinase
B. Gastrointestinal hypermotility
C. Kyphoscoliosis
D. Sinus bradycardia
C. Kyphoscoliosis
85
CREST syndrome is commonly associated with what disease?
A. Multiple Sclerosis
B. Scleroderma
C. DMD
D. Myasthenia Gravis
B. Scleroderma
86
Tensilon Test with Edrophonium improves what type of crisis?
A. Myasthenic
B. Cholinergic
A. Myasthenic
87
RA results in increased pain at what time of day?
A. Afternoon
B. After work
C. Morning
D. Night
C. Morning
88
Airway concerns in RA include which of the following? (2)
A. Atlantoaxial Subluxation
B. Increased Cricoarytenoid Laxity
C. TMJ movement limitation
D. Increased aspiration risk
A. Atlantoaxial Subluxation
C. TMJ movement limitation
89
Which of the following is not a common manifestation of SLE?
A. Serositis
B. Malar Rash
C. Nephritis
D. Asymmetric Arthritis
D. Asymmetric Arthritis
90
Which of the following are triggers for MH? (2)
A. N2O
B. Ryanodex
C. Anectine
D. Isoflurane
C. Anectine
D. Isoflurane
91
Horners Syndrome occurs as a result of which blockade?
A. Stellate Ganglion
B. Interscalene
C. Brachial Plexus
D. Lumbar Plexus
A. Stellate Ganglion
