Musculoskeletal disorders Exam 2 Flashcards
What is the pathophysiology of scleroderma?
- Autoimmune disease, excessive collagen production
- Hardening/tightening of the skin and connective tissue
- vascular injury/obliteration
- tissue fibrosis and organ sclerosis
What are the 3 types of scleroderma?
- Localized - skin, face, trunk, limbs
- limited cutaneous system - localized + CREST syndrome
- diffuse cutaneous system - rapidly progressive, CV involvment
What mnemonic guides the main symptoms associated with scleroderma?
CREST
* Calcinosis (Ca deposits)
* Raynaud’s
* Esophageal dysfunction
* Sclerodactyly (tight hands)
* Telangiectasia’s (small dilated blood vessels).
What skin and musculoskeletal abnormalities might be seen with scleroderma?
- Taut skin
- Contractures
- myopathy
What can happen to nerves with scleroderma?
Nerve Compression
What airway and pulmonary considerations exist for scleroderma?
- Pulmonary fibrosis
- Decreased airway compliance
What CV considerations exist for scleroderma?
- Systemic HTN and PH
- Dysrhythmias
- Small artery vasospasm’s (Raynaud’s)
- CHF
What treatments are used for scleroderma?
- Symptom alleviation
- ACE-inhibitors (renal crisis protection)
- Digoxin (improve CO)
- Steroids
- octreotide/PPIs
What GI symptoms exist for scleroderma?
- Xerostomia (dry mouth)
- GI tract fibrosis
- Poor dentition
- GERD
What dose of metoclopramide would be utilized for GI tract fibrosis from scleroderma?
Trick question. Metoclopramide is not effective in these patients.
What scleroderma anesthesia management considerations are there?
- avoid increasing PVR
- IV/A-line access
- Aspiration
- normothermia
What is Duchenne’s Muscular Dystrophy (DMD)?
- Genetic disorder - mutation of dystrophin gene (X chromosome)
- affects Skeletal muscles
What is dystrophin? What does it do?
- a large protein that stabilizes the muscle membrane
- without it muscle integrity breaks down
- progressive muscle loss
Who does it commonly affect and at what age? What are the symptoms?
- boys ages 2-5 years old
- waddling gait, frequent falling, can’t climb stairs, Gower’s sign
What is the progression of DMD?
- W/C bound by 8-10 y/o
- Deterioration in muscle strength
- Death at 20-25 y/o
- CHF and/or pneumonia
What s/s are seen with DMD?
- CNS - intellectual disability
- MS - kyphosis, muscle atrophy, ↑ CK, long bone fx
- CV - ↑ HR, cardiomyopathy, short PR
- 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, secretions
- CV - Get pre-op EKG & echo
- GI - delayed gastric emptying.
What drug should be avoided with DMD patients?
- Succinylcholine (Rhabdo & ↑K⁺)
- use NDMBs
What type of anesthesia is preferable for a DMD patient?
Regional (vs GA)
Why might one use less volatile gases with DMD patients?
- ↑risk of malignant hyperthermia
- Ensure you have Dantrolene
What is the pathophysiology of myasthenia gravis?
- Autoimmune: antibodies against post-synaptic AChR
- α-subunits of AChR antibodies
- Muscle weakness w/ rapid exhaustion of voluntary muscles
What is the classic symptom of MG?
- muscle weakness and fatigue that worsens with activity
- improves with rest
What are the classifications of MG?
Type I: limited involvement of extraocular muscles
Type IV: severe muscle weakness (progression from Type I or II)
Type III: acute onset < 6months, high mortality
What organ is linked with the production of anti-ACh receptor antibodies?
Thymus.
What signs/symptoms might be seen with myasthenia gravis?
- Ptosis, diplopia (double vision)
- Dysphagia, dysarthria
- Muscle weakness
- myocarditis
what other disease(s) is MG associated with? (4)
- RA
- SLE
- pernicious anemia
- hyperthyroidism
Differentiate Myasthenic Crisis and Cholinergic Crisis.
- Myasthenic Crisis - insufficient drug therapy
- severe muscle weakness resulting respiratory failure
- Cholinergic Crisis - excessive anticholinergic treatment
- SLUDGE-M symptoms, profound weakness
How do we diagnose myasthenia gravis?
- Edrophonium/Tensilon Test (cholinesterase inhibitor)
- 1-2 mg IVP
- Myasthenia symptoms improve with injection = (+) test.
what is acetylcholinesterase? How is it targeted as treatment for MG?
- An enzyme that breaks down acetylcholine in the NMJ
- drug therapy targets acetylcholinesterase to prolong ACh action
What drugs are the firstline treatment for Myasthenia Gravis? What would be done if drugs were ineffective?
- Anticholinesterase: Pyridostigmine > neostigmine (lasts longer, less S/E)
- Dose: max. 120mg Q3h
- Surgical Thymectomy = remission, less drugs
What drugs/treatments other than pyridostigmine or surgery could be used for myasthenia gravis?
- Immunosuppression: Corticosteroids, Azathioprine, Cyclosporine, Mycophenolate
- Immunotherapy: Plasmapheresis, Immunoglobulin (IVIG)
What anesthetic considerations exist for myasthenia gravis?
- Aspiration risk & weakened respiratory muscles.
- hypersensitivity to NMBs (intubate without if possible).
- No succinylcholine (resistant to it)
- intubate without NMBD
Why are MG patients resistant to succinylcholine?
- usually on pyridostigmine = increased ACh levels, less binding sites for sux
- antibodies = fewer binding sites for succinylcholine
What is osteoarthritis (OA)? What makes the pain better?
- Degeneration of articular cartilage with minimal inflammation.
- Pain with motion, relieved by rest
- AM stiffness disappears with movement
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 are the treatments for osteoarthritis?
- PT & exercise
- Maintenance of muscle function
- Pain relief (NO CORTICOSTEROIDS, not immune related)
- Joint replacement surgery.
Are osteoarthritis or rheumatoid arthritis patients prescribed corticosteroids?
Rheumatoid arthritis = Yes
Osteoarthritis = No
What anesthetic considerations exist for OA?
- Airway/cervical spine ROM
- consider fiberoptic or VAL
What is rheumatoid arthritis? What hand condition is often seen on inspection?
- Auto-immune systemic inflammatory disease.
- Swelling of the Proximal Interphalangeal, metacarpophalangeal
- boutonniere deformity
What are common symptoms in RA?
- Painful synovial inflammation
- Morning stiffness, remains until later in day
- Symmetrical distribution of several joints
- Fusiform swelling
- Synovitis of TMJ
RA affects most joints except?
- Thoracic
- Lumbosacral spine
Problems with the TMJ is associated with which disorder?
Rheumatoid Arthritis
Why do we need to practice caution during intubation in patients with RA?
- Atlantoaxial subluxation (spinal cord compression)
- Cricoarytenoid arthritis = swelling, redness of arytenoids, and upper airway obstruction
- TMJ limitation
What is atlantoaxial subluxation?
- abnormal instability of C1 and C2
- Odontoid process protrudes into the foramen magnum
- spinal cord compression
What CV symptoms can be seen with RA? Pulmonary?
- Pericarditis
- accelerated coronary atherosclerosis
- Restrictive lung changes
What two facial symptoms are often seen with RA?
- Keratoconjunctivitis sicca (dry eye)
- Xerostomia (dry mouth)
- “Sjorgen Syndrome”
What are treatments for rheumatoid arthritis?
- NSAIDs, COX inhibitors
- Corticosteroids
- DMARDs = methotrexate
- TNF-α inhibitors & Interleukin-1 inhibitors
- surgery
Compare and contrast DMARDs vs TNF-α inhibitors & Interleukin-1 inhibitors in how they treat rheumatoid arthritis.
- DMARDs (methotrexate) slow disease progression but have slow onset.
- TNF-α & IL1 inhibitors faster onset than DMARDs (TNF-α > DMARDs > IL1 inhibitors)
What anesthesia considerations exist for rheumatoid arthritis?
- Airway complications by atlantoaxial subluxation or TMJ.
- Severe RA lung disease.
- Stress dose steroids may be necessary
- protect dry eyes
What is a malar rash? What pathology is it characteristic of?
- Butterfly rash across the bridge of the nose and cheeks
- SLE
What is SLE? who does it commonly affect?
- Autoimmune disease targeting self-tissues (multiorgan)
- Young women 15-40 y/o
- African Americans
SLE typical manifestations?
- antinuclear antibodies
- malar rash
- thrombocytopenia
- serositis
- nephritis
What pathology is this and what are these lesions called?
- Discoid lupus lesions
- SLE
What type of rash is depicted below? What often causes it?
- Maculopapular rash characteristic of SLE
- exposure to the sun
What cardiac symptoms are seen with SLE?
- Pericarditis
- CAD
- Raynaud’s
What type of arthritis is seen with SLE?
- Symmetrical; no spinal involvement
- avascular necrosis of femoral head
- polyarthritis
What pulmonary symptoms are characteristic of SLE?
- Lupus pneumonia
- Vanishing Lung syndrome (elevated diaphragm)
- Restrictive lung disease
What is the most common cause of death for SLE patients?
- CAD
- accelerated with use of corticosteroids
What drugs are utilized to treat SLE?
- NSAIDs or ASA
- Antimalarials (hydroxychloroquine & quinacrine)
- Corticosteroids
- Immunosuppressants (methotrexate, azathioprine)
What anesthesia considerations exist for SLE patients?
- Recurrent laryngeal nerve palsy
- Cricoarytenoid arthritis
- Stress dose steroids likely necessary.
Which nerve is most likely to be damaged in SLE?
Recurrent laryngeal nerve
What is the MOA of malignant hyperthermia?
- Genetic mutation causing hypermetabolic syndrome
- ryanodine receptor (RYR1)
- dihydropyridine receptor
What are the most common drug causes of Malignant hyperthermia?
- volatiles
- succinylcholine
What are the early signs of malignant hyperthermia?
- ↑CO₂, ↑HR, ↑RR
- masseter 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 is the treatment for MH?
- D/C triggers
- Hyperventilate with 100% O2
- change aesthesia machine
- Dantrolene 20mg + 3g mannitol in 60 ml SW
What is initial Dantrolene dosing? What is the max dose?
- Initial: 2.5mg/kg
- Max: 10mg/kg
How is MH testing done?
- Muscle biopsy
- 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.
Preoperative findings of Duchenne muscular dystrophy include:
A. Decreased serum creatine kinase
B. Gastrointestinal hypermotility
C. Kyphoscoliosis
D. Sinus bradycardia
C. Kyphoscoliosis
Besides dantrolene, what treatment options are used for MH?
Hyperkalemia treatment
* Bicarb
* Calcium chloride/gluconate
* Insulin/dextrose
Hyperthermia treatment
* cold IV crystalloids
* cooling therapies
What is horners syndrome? What blockade causes this? What blockade can also be associated with this blockade?
- Ptosis, Miosis, Anhidrosis (on affected side)
- Stellate ganglion blockade
- phrenic nerve blockade => respiratory complications
