Musculoskeletal disorders Flashcards
DMD is most common in what population?
male 2-5yo
How do you diagnose DMD?
you’ll see the patient falling, can not walk up stairs, waddling gait
pseudo-hypertrophy muscular dystrophy will have a ___ CK lab value
High
- leads to hyperkalemia and kidney failure
Muscular dystrophy EKG
prolongs PR interval
Tall R waves
Large Q waves in the limb leads
Muscular dystrophy pulmonary symptoms
weak cough, OSA, pulm HTN
How does having a weak cough alter anesthesia plan?
- don’t over sedate
- may was to avoid NMB (you want to use suggamedex)
- Patient will usually need to stay on the ventilator for a prolonged time
- will try and do a regional anesthetic
Muscular dystrophy patients are at increased risk of _____
aspiration due to delayed gastric emptying
avoid using _____ in Muscular dystrophy patients
Sux (no reversal)
- these patients have an increase risk of malignant hyperthermia (careful with volatiles)
this can also add to the hyperkalemia
What is a good medication for sedating a pediatric patient short term?
ketamine (disassociation) short term
Myasthenia Gravis is a _____
chronic autoimmune disorder developed in later adult hood
Getting up and walking around can cause exhaustion in a pt with _______
Myasthenia Gravis
Classifications of MG
type 1 involves the eyes and type 4 is a severe disbility
Symptoms of MG
Eyes
Secretions
Speaking
Movement
Cardiac
Ptosis, diplopia, and dysphagia
Dysarthria and difficulty handling saliva
Isolated respiratory failure
Arm, leg, or trunk muscle weakness
Myocarditis
Autoimmune diseases associated
RA, SLE, pernicious anemia, hyperthyroidism
MG crisis usually happens when a patient is ____
traveling
MG crisis presents with severe ___
muscle weakness
- looks like cholinergic crisis
What medications have cholinergic effects?
scopolamine
glycopyrolate
zofran
phenergen
Tensilon Test
Give 1-2 mg of edrophonium and if the muscle weakness gets better it is MG and not cholinergic crisis
What can you give to take out the muscle tone in a patient without using a NMB?
Robaxin, Spinal anesthesia
Treatment of MG
thymectomy
- this is a big surgery and can help with remission and wont need biologic agents. but this takes a while until you show improvement
What medications do MG patients usually take
corticosteroids (give the stress dose)
immunosuppressant
immunoglobuliln
plasmapheresis
_____ is a great alternative to sux in MG
Remifentanyl
Osteoarthritis is largely in what three joints?
knees, hips, shoulders
What causes Osteoarthritis ?
repetitive mechanical stress
Osteoarthritis vs rheumatoid arthritis symptoms
Osteoarthritis will have overuse of the joints while RA doesnt require that
- you will he heberden nodes
Osteoarthritis treatment
exercise and PT
pain relief such as heat, NSAIDS, TENs unit, acupuncture, injection of stem cells, put dextrose in the joint, inject platelet rich plasma
Osteoarthritis may cause ____ ____ ___ ____ during intubation
limited range of motion
Rheumatoid arthritis tends to mainly affect what joints?
interphalangeal and metacarpophalangeal joints (hands and feet)
What medications are RA usually on?
immunosuppressant’s
- viruses can be devastating to these patients
RA is more common in ____ than _____
females than males
is RA usually a single joint or multiple joints?
Could be both
RA patients feel worse in the _____
morning
Osteoarthritis patients feel worse ____
in the evening
_____ in RA can cause pain on opening their mouth
TMJ
- heat or PT can help with this
RA is rarely seen in what place in the spine?
T and L
usually in the cervical spine
Atlantoaxial subluxation is common in what patients?
Down syndrome or RA
cricoarytenoid arthritis symptoms
Acute – hoarseness, dyspnea, and stridor w/ tenderness over the larynx; swelling and redness of arytenoids
Chronic – asymptomatic or variable degrees of hoarseness, dyspnea, and upper airway obstruction
Very high risk for vocal cord paralysis
cricoarytenoid arthritis may cause what after intubation?
swelling and the patient may need to stay intubated
RA symptoms
CV
Pulmonary
Hematology
CV: Pericarditis, accelerated coronary atherosclerosis
Pulmonary: Restrictive lung changes, movement of the chest wall can cause pain
Hematology: Anemia, neutropenia, elevated platelets
Keratoconjunctivitis sicca and xerostomia
RA medications for treatment
DMARDS (methotrexate)
TNF inhibitors and IL-1 inhibitors work better than DMARDS but take a long time
TNF have severe side effects and will move to IL-1
Anesthesia concerns with RA
Airway
- Atlantoaxial subluxation
- TMJ limitation – video laryngescope
- Cricoarytenoid joints
Severe rheumatoid lung disease
Protect eyes
Stress dose steroids
How would a lupus patient present with avascular necrosis?
pain in the hip, thigh, knee
Lupus symptoms
CNS
CV
Pulmonary
Renal
Liver
NM
Hematology
Skin
Polyarthritis and dermatitis
Symmetrical arthritis
No spinal involvement
Avascular necrosis of femoral head or condyle
Hip pain, difficulty walking – need CT or MRI
CNS: Cognitive dysfunction, psychological changes
CV: Pericarditis, coronary atherosclerosis, Raynaud’s
Pulmonary: Lupus pneumonia, restrictive lung disease, vanishing lung syndrome (diaphragm will move up into the chest) pleural effusions, hypoxic
Renal: Glomerulonephritis, decreased GFR
GI/Liver: ABD pain, pancreatitis, elevated liver enzymes
NM: Skeletal muscle weakness
Hematology: Thromboembolism, thrombocytopenia, hemolytic anemia
Skin: Butterfly-shaped malar rash, discoid lesions, alopecia
Vanishing lung syndrome in lupus
diaphragm is moved up into the chest
Antimalarial drugs are used for what autoimmune disorder?
lupus
Hydroxychloroquine and quinacrine
Recurrent laryngeal nerve palsy presentation
hoarseness, unilateral
If bilateral the patient wont be able to breath
What is the genetic mutations in malignant hyperthermia?
Ryanodine receptor - RYR1 gene
Dihydropyridine receptor
What happens with calcium in MH?
uncontrolled elevation of calcium in the sarcoplasmic
If the patient has a high RR and the CO2 is still rising worry about _____
MH
How to treat MH
- stop whatever caused is. If it is a volatile agent then take them off the vent entirely and hyperventilate the patient. Then get a new anesthesia machine
- Give Dantrolene (usually will have to give 10-20 vials)
- cool them off internally and externally
what is the initial dose of dantrolene
2.5mg/kg to 10mg/kg
Who can you call during an MH case?
Not ghost busters
1-800-MH-HYPER
What is soda lime?
it absorbs the CO2
Tensolin test improves what disease
MG
What is not a common manifestation of SLE?
asymmetric rash
The mortality rate of MH is _____
50%
What agents are triggers for MH (2)
Anectine and isoflurane
Horners syndrome occurs as a result of what blockade?
Stellate Ganglion is blocked with inter scalene block
CREST syndrome stands for what?
Calcinosis, raynauds, esophageal dysfunction, sclerodactyl, telangiectasis
This would be limited cutaneous scleroderma
Involvement of the skin of the face, trunk, and distal limbs is _____ scleroderma
localized, others include
Limited cutaneous system sclerosis - Usually a combination of scleroderma features; CREST syndrome
Diffuse cutaneous system sclerosis - Rapidly progressive disease, with generalized skin involvement and cardiovascular complications with vascular involvement, coronary artery disease, cardiomyopathy, and hypertension
what disease is characterized by excessive deposit of collagen in the extracellular
Scleroderma
Why do you have to be cautious of Aline placement in pts with scleroderma?
because they could already have radial or ulnar neuropathy and this can make it worsewh
what induction drug is recommended for scleroderma
etomidate
in scleroderma renal crisis is precipitated by ____
corticosteroids
___ will not work for the treatment of GI motility issues in pt with scleroderma
reglan
Somatostatin analogues such as octreotide are effective in improving small intestine hypomotility,
What drugs are used to treat the raynauds associated with scleroderma?
CCB
What are airway considerations with scleroderma patients?
Mandibular motion, small mouth opening, neck ROM, oral bleeding, atlantooccipital sublux
Scleroderma pt have an increased risk of _______
bleeding
VTE is very common in pt with scleroderm. What can be done to prevent this?
5000 heparin
Walk them
Pressure stockings
Which gases do you want to try an avoid with MD?
halogenated!!! Which is literally all of our gases
why dont you want to over sedate a patient with MD?
Because they already have a weak cough, you will make the respiratory reflexes worse
80% of receptors in the NMJ can be lost in ___
MG
In MG skeletal muscles innervated by _____ are especially vulnerable to weakness
Cranial nerves
Skeletal muscles innervated by cranial nerves (ocular, pharyngeal, and laryngeal muscles) are especially vulnerable
Which muscular disease can have stroke like symptoms?
MG
What antibiotics are contraindicated in MG patients and why?
ABX mycins (gentamicin, streptomycin, tobramycin)
contraindicated in myasthenia gravis.It can cause clinically significant muscle weakness in myasthenia patients resulting in respiratory depression.
fusiform swelling is described in what disease?
RA
