Musculoskeletal disorders Exam 2 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 (Ca deposits)
- Raynaud’s
- Esophageal reflux
- 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 does xerostomia mean?
Dry mouth.
What treatments are used for scleroderma?
- Symptom alleviation
- ACE-inhibitors
- Digoxin
- Steroids
What airway and pulmonary considerations exist for scleroderma?
- Pulmonary fibrosis (↓ compliance)
- Decreased ROM for airway
What CV considerations exist for scleroderma?
- Systemic and pulmHTN
- Dysrhythmias
- Small artery vasospasm’s
- CHF
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 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?
- Mutation in dystrophin gene 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 - kyphosis, muscle atrophy, ↑ CK
- 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
- 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?
- DMD patients have ↑risk of malignant hyperthermia.
- Ensure you have Dantrolene.
What is the pathophysiology of myasthenia gravis?
- ↓ functional 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 receptor 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 (double vision)
- Dysphagia
- dysarthria
- Muscle weakness.
Differentiate Myasthenic Crisis and Cholinergic Crisis.
- Myasthenic Crisis - severe respiratory muscle weakness or airway collapse with 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 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.
What joints are usually spared by rheumatoid arthritis?
Thoracic & Lumbosacral spine.
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 coronary atherosclerosis
- Restrictive lung changes.
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 have slow onset.
- 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 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
- 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 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.
Preoperative findings of Duchenne muscular dystrophy include:
A. Decreased serum creatine kinase
B. Gastrointestinal hypermotility
C. Kyphoscoliosis
D. Sinus bradycardia
C. Kyphoscoliosis
What is SLE?
Autoimmune disorder characterized by multisystem chronic inflammation
What are the most common drug causes of Malignant hyperthermia?
- volatiles
- succinylcholine
What is the MOA of malignant hyperthermia?
Genetic mutation that causes dysfunction of ryanodine receptor leading to hypermetabolic syndrome
Besides dantrolene, what treatment options are used for MH?
Hyperkalemia treatment
* Bicarb
* Calcium
* 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
