Musculoskeletal Diseases (Exam II) Flashcards
What is the pathophysiology of scleroderma?
- Autoimmune disease w/ progressive tissue fibrosis/sclerosis and vascular injury.
What mnemonic guides the main symptoms associated with scleroderma?
Expound on the mnemonic.
- Calcinosis
- Raynaud’s
- Esophageal reflux
- Sclerodactyly
- Telangiectasia’s
What skin and musculoskeletal abnormalities might be seen with scleroderma?
- Taut skin
- Contractures & myopathy
What can happen to nerves with scleroderma?
Compression
What does xerostomia mean?
Dry mouth
What treatments are used for scleroderma?
- Symptoms alleviation
- ACE-inhibitors
- Digoxin
- Steroids
What is the main treatment for scleroderma?
ACEi
What airway and pulmonary considerations exists for scleroderma?
- Pulmonary fibrosis (↓ compliance)
- Decreased ROM for airway
What CV considerations exists for scleroderma?
- Possible pulmHTN
- Dysrhythmias
- Small artery vasospasm’s
- CHF
What GI symptoms exist for scleroderma?
- Xerostomia
- GI tract fibrosis
- Poor dentition
- GERD
What renal considerations should be made with scleroderma?
Decreased renal blood flow and systemic HTN
What is used to treat renal crisis with scleroderma?
ACEi
What causes renal crisis with scleroderma?
Corticosteroids
What dose of metoclopramide would be utilized for GI tract fibrosis from scleroderma?
Trick question. Metoclopramide would not work in this scenario.
What scleroderma anesthesia management considerations are there?
What is Duchenne’s Muscular Dystrophy (DMD)?
What initial symptoms are present at 2-5 years of age?
- X-linked dystrophin disorder resulting in muscle atrophy.
- (Ages 2-5) = waddling gait, frequent falling, can’t climb stairs, Gower’s sign.
What s/s are seen with DMD?
List:
CNS
Musculoskeletal
CV
Pulm
GI
- CNS - intellectual disability
- MS - kyphoscoliosis, muscle atrophy, ↑ CK
- CV - ↑ HR, cardiomyopathy, short PR & tall R-wave
- Pulm - weakened respiratory muscles and weak cough, OSA
- GI - hypomotility & gastroparesis
What are the anesthetic concerns and interventions relevant to DMD patients?
- Airway
- Pulmonary
- CV
- GI
- Airway - weak laryngeal reflexes & cough
- Pulm - weakened muscles
- CV - Get pre-op EKG & echo
- GI - delayed gastric emptying
What are the common causes of death with DMD?
CHF and/or pneumonia
What drug should be avoided with DMD patients?
- Succinylcholine (Rhabdo & ↑K⁺)
use NDMBs
What type of anesthesia is prefereable for a DMD patient?
Regional (vs GA)
Why might one use less volatile gasses with DMD patients?
- DMD patients have ↑risk of malignant hyperthermia.
Ensure you have Dantrolene
What sedation considerations are there for DMD patients?
Don’t oversedate
What is the pathophysiology of myasthenia gravis?
- ↓ function of NMJ post-synaptic ACh receptors.
αlpha sub-units of ACh receptor are bound by antibodies.
What organ is linked with the production of anti-ACh antibodies?
- Thymus
Which condition is characterized by partial recovery with rest?
Myasthenia Gravis
What test is used to diagnose myasthenia gravis?
Edrophonium/Tensilon Test
- 1-2 mg IVP
- Myasthenia symptoms improve with injection = (+) test
What signs/symptoms might be seen with myasthenia gravis?
- Ptosis & diplopia
- Dysphagia & dysarthria
- Muscle weakness
What is ptosis?
Drooping of the eyelid
What is diplopia?
Double vision
Differentiate Myasthenic Crisis and Cholinergic Crisis.
- Myasthenic Crisis - Insufficient drug therapy and resulting respiratory failure.
- Cholinergic Crisis - too much -stigmine drug = SLUDGE-M symptoms.
What drugs are the firstline treatment for Myasthenia Gravis?
What would be done if drugs were ineffective?
- Pyridostigmine (AChesterase inhibitors)
- Surgical Thymectomy
What drugs/treatments other than pyridostigmine or surgery could be used for myasthenia gravis?
- Corticosteroids
- Azathioprine
- Cyclosporine
- Mycophenolate
- Plasmapheresis
- Immunoglobulin
What anesthetic considerations exist for myasthenia gravis?
- Aspiration risk & weakened respiratory muscles.
- Sensitivity to NMBs (intubate without if possible)
- No succinylcholine (resistant to it)
What is osteoarthritis (OA)?
What makes the pain better?
- Degeneration of articular cartilage with minimal inflammation.
- Pain better at rest.
- Pain is worse with motion.
What are Heberden nodes?
What disease process do they indicate?
- Bony swellings of the distal interphalangeal joints.
- Osteoarthritis
What spinal complications occur from osteoarthritis?
- Vertebral degeneration
- Nucleus pulposus herniation
- Nerve root compression
What joints are most affected by OA?
Knees and hips
What parts of the spinal cord are affected by OA?
Middle to lower C spine and L spine
What are the treatments for osteoarthritis?
- PT & exercise
- Maintenance of muscle function
- Pain relief
- Joint replacement surgery
Are osteoarthritis or rheumatoid arthritis patients prescribed corticosteroids?
- RA patients (no steroids for OA)
What anesthetic considerations exist for OA?
- Airway ROM
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.
What joints are usually spared by rheumatoid arthritis?
- Thoracic & Lumbosacral spine
Is fusiform swelling associated with OA or RA?
RA
Is osteoarthritis or RA worse in the morning?
RA - improves throughout the day
Does osteoarthritis or RA worsen throughout the day?
Osteoarthritis
Is OA or RA an inflammatory condition?
RA
With this condition it is common to have synovitis of the temporomandibular joint.
Rheumatoid Arthritis
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)
What cardiac symptoms can be seen with RA?
Pulmonary?
- Pericarditis and accelerated CAD
- Restrictive lung changes
What is a specific pulmonary symptom of RA?
Rheumatoid nodules that resemble TB
What heme considerations are made with RA?
Anemia, neutropenia, elevated PLT
What two facial symptoms are often seen with RA?
- Keratoconjunctivitis sicca (dry eye)
- Xerostomia (dry mouth)
What drugs are used to treat rheumatoid arthritis?
- NSAIDs
- Corticosteroids
- DMARDs
- TNF-α inhibitors & Interleukin-1 inhibitors
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)
What anesthesia considerations exist for rheumatoid arthritis?
- Airway complications by atlantoaxial subluxation or TMJ.
- Severe RA lung disease
- Stress dose steroids may be necessary
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.
What pathology is this and what are these lesions called?
- Discoid lesions characteristic of SLE.
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.
What are 5 typical manifestations of SLE?
- Antinuclear antibodies
- Malar rash
- Thrombocytopenia
- Seroitis
- Nephritis
What type of anemia is common with SLE?
Hemolytic anemia
What cardiac symptoms are seen with SLE?
- Pericarditis
- CAD
- Raynaud’s
What type of arthritis is seen with SLE?
- Symmetrical w/ no spinal involvement but frequent breakdown of femoral head.
What pulmonary symptoms are characteristic of SLE?
- Lupus pneumonia
- Vanishing Lung syndrome
- Restrictive lung disease
What drugs are utilized to treat SLE?
- NSAIDs or ASA
- Antimalarials (HCQ & quinacrine)
- Corticosteroids
- Immunosuppressants
What anesthesia considerations exist for SLE patients?
- Recurrent laryngeal nerve palsy
- Cricoarytenoid arthritis
- Stress dose steroids likely necessary
What condition often has recurrent laryngeal nerve paralysis?
Lupus (SLE)
What are the early signs of malignant hyperthermia?
- ↑CO₂
- ↑HR
- ↑RR
- Jaw muscle spasm
- Peaked T waves
- Acidosis
- Muscle rigidity
What are the late signs of malignant hyperthermia?
- Hyperthermia
- Rhabdo & cola-urine
- ↑CPK
- VTach/Vfib
- Acute renal failure
- DIC
What receptors are altered with MH?
- Ryanodine (RYR1)
- Dihydropyridine
What electrolyte change occurs with MH?
Uncontrolled elevation of sarcoplasmic Ca
What problem occurs with altered Ca stores in MH?
- Sustained activation of muscle contraction
- Rhabdo
What paralytic and volatile gas is safe for MH?
- Non-depolarizing NMB
- Nitrous
What is initial Dantrolene dosing?
What is the max dose?
- Initial: 2.5mg/kg.
- Max: 10mg/kg
How is MH testing done?
- Muscle biopsy and halothane + caffeine contracture test.
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.
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
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
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
Preoperative findings of Duchenne muscular dystrophy include:
A. Decreased serum creatine kinase
B. Gastrointestinal hypermotility
C. Kyphoscoliosis
D. Sinus bradycardia
C. Kyphoscoliosis
