Musculoskeletal disorders Exam 2 Flashcards
1
Q
What is the pathophysiology of scleroderma?
A
- Autoimmune disease, excessive collagen production
- Hardening/tightening of the skin and connective tissue
- vascular injury/obliteration
- tissue fibrosis and organ sclerosis
2
Q
What are the 3 types of scleroderma?
A
- Localized - skin, face, trunk, limbs
- limited cutaneous system - localized + CREST syndrome
- diffuse cutaneous system - rapidly progressive, CV involvment
3
Q
What mnemonic guides the main symptoms associated with scleroderma?
A
CREST
* Calcinosis (Ca deposits)
* Raynaud’s
* Esophageal dysfunction
* Sclerodactyly (tight hands)
* Telangiectasia’s (small dilated blood vessels).
4
Q
What skin and musculoskeletal abnormalities might be seen with scleroderma?
A
- Taut skin
- Contractures
- myopathy
5
Q
What can happen to nerves with scleroderma?
A
Nerve Compression
6
Q
What airway and pulmonary considerations exist for scleroderma?
A
- Pulmonary fibrosis
- Decreased airway compliance
7
Q
What CV considerations exist for scleroderma?
A
- Systemic HTN and PH
- Dysrhythmias
- Small artery vasospasm’s (Raynaud’s)
- CHF
8
Q
What treatments are used for scleroderma?
A
- Symptom alleviation
- ACE-inhibitors (renal crisis protection)
- Digoxin (improve CO)
- Steroids
- octreotide/PPIs
9
Q
What GI symptoms exist for scleroderma?
A
- Xerostomia (dry mouth)
- GI tract fibrosis
- Poor dentition
- GERD
10
Q
What dose of metoclopramide would be utilized for GI tract fibrosis from scleroderma?
A
Trick question. Metoclopramide is not effective in these patients.
11
Q
What scleroderma anesthesia management considerations are there?
A
- avoid increasing PVR
- IV/A-line access
- Aspiration
- normothermia
12
Q
What is Duchenne’s Muscular Dystrophy (DMD)?
A
- Genetic disorder - mutation of dystrophin gene (X chromosome)
- affects Skeletal muscles
13
Q
What is dystrophin? What does it do?
A
- a large protein that stabilizes the muscle membrane
- without it muscle integrity breaks down
- progressive muscle loss
14
Q
Who does it commonly affect and at what age? What are the symptoms?
A
- boys ages 2-5 years old
- waddling gait, frequent falling, can’t climb stairs, Gower’s sign
15
Q
What is the progression of DMD?
A
- W/C bound by 8-10 y/o
- Deterioration in muscle strength
- Death at 20-25 y/o
- CHF and/or pneumonia
16
Q
What s/s are seen with DMD?
A
- 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.
17
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, secretions
- CV - Get pre-op EKG & echo
- GI - delayed gastric emptying.
18
Q
What drug should be avoided with DMD patients?
A
- Succinylcholine (Rhabdo & ↑K⁺)
- use NDMBs
19
Q
What type of anesthesia is preferable for a DMD patient?
A
Regional (vs GA)
20
Q
Why might one use less volatile gases with DMD patients?
A
- ↑risk of malignant hyperthermia
- Ensure you have Dantrolene
21
Q
What is the pathophysiology of myasthenia gravis?
A
- Autoimmune: antibodies against post-synaptic AChR
- α-subunits of AChR antibodies
- Muscle weakness w/ rapid exhaustion of voluntary muscles
22
Q
What is the classic symptom of MG?
A
- muscle weakness and fatigue that worsens with activity
- improves with rest
23
Q
What are the classifications of MG?
A
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
24
Q
What organ is linked with the production of anti-ACh receptor antibodies?
A
Thymus.
25
What signs/symptoms might be seen with myasthenia gravis?
* **Ptosis, diplopia (double vision)**
* Dysphagia, dysarthria
* Muscle weakness
* myocarditis
26
what other disease(s) is MG associated with? (4)
* RA
* SLE
* pernicious anemia
* hyperthyroidism
27
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
28
How do we diagnose myasthenia gravis?
* **Edrophonium/Tensilon Test** (cholinesterase inhibitor)
* **1-2 mg IVP**
* Myasthenia symptoms **improve** with injection = (+) test.
29
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**
30
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
31
What drugs/treatments other than pyridostigmine or surgery could be used for myasthenia gravis?
* **Immunosuppression**: Corticosteroids, Azathioprine, Cyclosporine, Mycophenolate
* **Immunotherapy**: Plasmapheresis, Immunoglobulin (IVIG)
32
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**
33
Why are MG patients resistant to **succinylcholine**?
1. usually on **pyridostigmine** = increased ACh levels, less binding sites for sux
2. **antibodies** = fewer binding sites for succinylcholine
34
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
35
What are **Heberden nodes**? What disease process do they indicate?
* Bony swellings of the **distal interphalangeal** joints.
* Osteoarthritis.
36
What spinal complications occur from osteoarthritis?
* Vertebral degeneration,
* Nucleus pulposus herniation,
* Nerve root compression.
37
What are the treatments for osteoarthritis?
* PT & exercise
* Maintenance of muscle function
* Pain relief **(NO CORTICOSTEROIDS, not immune related)**
* Joint replacement surgery.
38
Are osteoarthritis or rheumatoid arthritis patients prescribed corticosteroids?
Rheumatoid arthritis = Yes
**Osteoarthritis = No**
39
What anesthetic considerations exist for OA?
* Airway/cervical spine ROM
* consider fiberoptic or VAL
40
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**
41
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**
42
RA affects most joints except?
* Thoracic
* Lumbosacral spine
43
Problems with the TMJ is associated with which disorder?
Rheumatoid Arthritis
44
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
45
What is atlantoaxial subluxation?
* abnormal instability of **C1** and **C2**
* **Odontoid process** protrudes into the foramen magnum
* **spinal cord compression**
46
What CV symptoms can be seen with RA? Pulmonary?
* **Pericarditis**
* accelerated coronary **atherosclerosis**
* Restrictive lung changes
47
What two facial symptoms are often seen with RA?
* **Keratoconjunctivitis sicca** (dry eye)
* **Xerostomia** (dry mouth)
* **"Sjorgen Syndrome"**
48
What are treatments for rheumatoid arthritis?
* **NSAIDs**, COX inhibitors
* **Corticosteroids**
* **DMARDs = methotrexate**
* TNF-α inhibitors & Interleukin-1 inhibitors
* surgery
49
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)**
50
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
51
What is a **malar rash**? What pathology is it characteristic of?
* **Butterfly rash** across the bridge of the nose and cheeks
* SLE
52
What is SLE? who does it commonly affect?
* Autoimmune disease targeting self-tissues (multiorgan)
* Young women 15-40 y/o
* **African Americans**
53
SLE typical manifestations?
* antinuclear antibodies
* malar rash
* thrombocytopenia
* serositis
* nephritis
54
What pathology is this and what are these lesions called?
* **Discoid lupus lesions**
* SLE
55
What type of rash is depicted below? What often causes it?
* **Maculopapular rash** characteristic of SLE
* exposure to the sun
56
What cardiac symptoms are seen with SLE?
* **Pericarditis**
* CAD
* Raynaud’s
57
What type of arthritis is seen with SLE?
* **Symmetrical**; **no spinal involvement**
* **avascular necrosis** of femoral head
* **polyarthritis**
58
What pulmonary symptoms are characteristic of SLE?
* Lupus pneumonia
* Vanishing Lung syndrome (elevated diaphragm)
* Restrictive lung disease
59
What is the most common cause of death for SLE patients?
* CAD
* accelerated with use of **corticosteroids**
60
What drugs are utilized to treat SLE?
* NSAIDs or ASA
* Antimalarials (**hydroxychloroquine** & quinacrine)
* Corticosteroids
* **Immunosuppressants** (methotrexate, azathioprine)
61
What anesthesia considerations exist for SLE patients?
* **Recurrent laryngeal nerve palsy**
* Cricoarytenoid arthritis
* **Stress dose steroids** likely necessary.
62
Which nerve is most likely to be damaged in SLE?
Recurrent laryngeal nerve
63
What is the MOA of malignant hyperthermia?
* Genetic mutation causing **hypermetabolic syndrome**
* **ryanodine receptor (RYR1)**
* **dihydropyridine receptor**
64
What are the most common drug causes of Malignant hyperthermia?
* volatiles
* succinylcholine
65
What are the **early signs** of malignant hyperthermia?
* **↑CO₂, ↑HR, ↑RR**
* **masseter muscle spasm**
* Peaked T waves
* Acidosis
* Muscle rigidity
66
What are the **late signs** of malignant hyperthermia?
* Hyperthermia
* Rhabdo & cola-urine
* ↑CPK
* VTach/Vfib
* Acute renal failure
* DIC
67
What is the treatment for MH?
* D/C triggers
* Hyperventilate with 100% O2
* change aesthesia machine
* Dantrolene 20mg + 3g mannitol in 60 ml SW
68
What is initial Dantrolene dosing? What is the max dose?
* Initial: **2.5mg/kg**
* Max: **10mg/kg**
69
How is MH testing done?
* Muscle biopsy
* halothane + caffeine contracture test
70
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.
71
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
72
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
73
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.
74
Preoperative findings of Duchenne muscular dystrophy include:
A. Decreased serum creatine kinase
B. Gastrointestinal hypermotility
C. Kyphoscoliosis
D. Sinus bradycardia
C. Kyphoscoliosis
75
Besides dantrolene, what treatment options are used for MH?
**Hyperkalemia treatment**
* Bicarb
* Calcium chloride/gluconate
* Insulin/dextrose
**Hyperthermia treatment**
* cold IV crystalloids
* cooling therapies
76
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
