Neuromuscular Flashcards
General questions to ask during neuromuscular assessment
1) Have you ever had a stroke, seizure/fit/convulsion, or paralysis?
2) Every been diagnosed with a tremor or Parkinson’s disease?
3) Have you ever had numbness/tingling/pins and needles in any of your extremities lasting more than 2 hours?
4) Have you ever had a nerve injury?
5) Ever have MS or other nervous system disease?
6) Ever have migraine headaches?
7) In the last year, have you taken any antidepressants, sedatives, tranquilizers, antiepileptics, or herbal meds?
8) Any pain in your joints? Limited ROM? Lower back pain?
9) Have you been able to perform all your activities at home and work in the last week/month/year?
10) Have you taken any pills or shots for pain in the last 6 months?
Effect of GA on normal protective pain reflexes
Takes them away
- Important to know ROM limitations and document their baseline
- Maintain their natural ROM during positioning
- May help to position to comfort BEFORE putting them to sleep (and document this!)
When would we assess the TMJ?
If the patient has trouble opening their mouth or if they have RA
What would we do if pt has limited ROM or pain in their TMJ?
Consider another mode of intubation (glidescope)
- Remember that on intubation, we scissor their mouth open very wide-we don’t want to hurt their TMJ if they have problems with it
Is snapping and clicking normal on TMJ assessment?
Yes
How to assess TMJ
1) Finger in the joint-ask to open and close
2) Ask them protrude their jaw and to move it side to side
Assessment of the shoulder girdle
1) Abduct arms to shoulder level
2) Arms vertical and above head with palms facing eachother
3) Hands behind neck with elbows to the side
4) Both hands behind the small of the neck
What is thoracic outlet syndrome?
Compression of the neurovascular bundle between the two scalene muscles near the first rib
- will manifest as pain/extremity discoloration when the arms are above the head
When should we test/ask about thoracic outlet syndrome?
For prone positioning
Hip assessment
1) Flexion- Hand under small of back for support, and bring their knee to their chest
2) Abduction- Stabilize the contralateral ASIS and abduct the leg closer to you. Stop once the iliac spine moves or the patient has pain!
When to perform hip assessment?
Lithotomy position
Function of the trigeminal nerve
Facial sensation and muscles of mastication
Corneal reflex (cotton ball method) tests what cranial nerve?
Trigeminal (sensation!!)
Test of the vagus nerve
Gag reflex, palate rises symmetrically when you say AHHH, any voice hoarseness?
Test for spinal accessory (CN XI)
Raising both shoulders and turning head against resistance
Elbow movement involves these nerves
Flexion- C5&6
Extension- C6-8
Finger abduction involves these nerves
C8, T1, and ulnar
Thumb opposition involves these nerves
C8, T1, median nerve
Hip flexion and adduction involves these nerves
L2-4
Hip abduction involves these nerves
L4-S1
Hip extension involves this nerve
S1
Knee extension involves these nerves
L2-L4
Knee flexion involves these nerves`
L4-S2
Dorsiflexion involves these nerves
L4&5
Plantar flexion involves this nerve
S1
Anesthesia is usually called to intubate with a GCS of ____ or less
8
How to score GCS
Eye opening- never (1) -spontaneous (4)
Best verbal response- none (1) - oriented (5)
Best motor response- None (1) - obeys commands (6)
Why is steroid therapy a big deal for anesthesia?
Because exogenous steroids send the message to the hypothalamus that we are making enough steroid. Causes suppression of the pituitary/adrenal axis, and prevents the patient from being able to cope appropriately with the stress of surgery
Who do we give supplementary steroids to?
Any patient who has received corticosteroid therapy for at least a month in the last 6-12 months
Meds that we SHOULD NOT GIVE if the patient is on an MAOI
Ephedrine
&
Meperidine (Demerol)- narcotic
How do MAOIs work?
MAOIs inhibit the degradation of monoamines in the synapse, increasing the amount of seratonin and NE available at the nerve terminal for uptake and storage
Meperidine is sometimes used in anesthesia for
post-op shivering
Examples of MAOIs
Iproniazad Isocarboxazid Phenelzine Moclobemide Befloxatone Brofaromine Selegiline (MAO-B for Parkinson's-- can lose selectivity at high doses)
What is methotraxate used for and what should we watch for?
Used in MS, RA, and ankylosing spondylitis
(used to treat autoimmune disease)
Watch for immunosuppression, anemia, thrombocytopenia, pulm toxicity, renal and hepatic toxicity
Check CBC, PFTs (if pulm s/s), LFTs (if liver symptoms), and chem panel (if renal s/s)
People with MS have an increased risk of ____ with surgery
relapse.
Explain to them that they are at risk for this, but you will do things like keep them warm to help prevent this from happening.
If we have a patient with MS, what kind of things do we want to know about them?
Immunosuppressant therapy? Remission and exacerbation intervals Severity and nature of symptoms (resp status) Previous triggers Any motor or visual impairment? Sensory disturbances? Seizures? Meds for seizures? ANS disturbances? (high resting HR, orthostatic hypotension) Emotional disturbances?
Most people on MS are on this type of med
Immunosuppressants (like methotrexate)
- See if they’ve had any recent illnesses of infections (take extra care with infection prevention)
- Find out what med they’re taking and how often
- Any steroids in the last year??
What is guillain barre?
A demyelinating disease of the peripheral nervous system, causing ascending paralysis.
Should we take people with guillaine barre for elective surgery?
No!
What should we look for if we are taking someone with GB to surgery?
Focus exam on the extend and severity of their current symptoms
- ANS DYSFUNCTION
- Facial paralysis (able to protect airway??)
- Trouble swallowing? (aspiration risk)
- Vent settings they’re on
- Paresthesias in the extremities
- Pain (HA, backache, muscle tenderness– on any meds for pain?)
- Decreased DTRs (part of the disease process)
Guillain barre and ANS dysfunction
Look at the trend in vital signs!!
Ask the nurse about how they tolerate position changes
- EKG (any recent arrhythmias)
- On ay meds to raise or lower BP?? (can have extremes in either direction)
For patients with Parkinson’s disease, we should ask if they were on this medication before it was taken off the market
Pergolide
- was causing valvular dysfunction
Questions to ask if someone has Parkinson’s
Age of diagnosis?
Recent exacerbations/hospitalizations?
Current and past symptoms (oculogyric crisis? when? how long did it last? what helped?)
ANS symptoms? (ortho hypo)
Difficulty swallowing?
Difficulty breathing?
Current medications? How often? What happens if you miss a dose?
Considerations for the patient with Parkinson’s
May have ANS symptoms
Issues with temperature regulation (may have to increase the temp of the OR)
Need to optimize their pulmonary stats
Note their natural ROM
Deactivate their deep brain stimulator if they have one
If your patient has a deep brain stimulator, what should you do?
Call neurosurgery to deactivate it before surgery– could be affected by the electrocautery
Considerations with the person with disc herniation or lower back pain?
Note their natural ROM (to influence your positioning and laryngoscopy)
Note their baseline motor strength and sensation
Are they on pain meds? What meds work best for them?
They are probably on NSAIDs and have the potential for blood loss (do a CBC and type and cross)
Risk for autonomic dysreflexia is lower if the injury is lower than `
T10
If spinal injury is above _____, baroreceptors are unable to compensate for the massive vasodilation
T4 or 5
May need to be placed on vasopressors
Considerations for the patient with an acute spinal injury
Remember that something acute and shitty JUST happened to them
- Want to know their fluid and blood status (get labs and cross blood)
- EKG/Chest x-ray
- Are they breathing well? On a ventilator?
- Other injuries associated with the event?
Considerations for the patient with a chronic spinal injury
- Any history of autonomic dysreflexia? What caused it?
- Ability to breath
- Skin integrity
- ROM (to determine comfortable positioning)
- Look at old OR/ICU records (previous response to pressors, tracheal suctioning, etc)
What increases the risk of peri-op stroke?
Recent TIA of CVA
When is the optimal for elective surgery after stroke?
No current guidelines- controversial
With things involving the head, what are we most concerned about?
Increased ICP– will alter drug choice and anesthetic management
- also thing about where you want the MAP and EtCO2 to be
Do we routinely test for serum levels of antiepileptics on our patients with seizures?
No, not if they have good seizure control.
Get a level if you feel they have been non-compliant.
What should we do if we have a patient coming in for elective surgery and their seizure disorder is not under control?
Cancel the case until the seizure disorder is optimized by a neurologist
Things to look at with the patient with Lupus
Any rashes? (so you’re not confused with an allergic reaction intra-op)
Renal function?
Cardiac function?
Pulm status (could cause restrictive disease)
GI issues? (prone to N/V)
Mentation? (CNS involvement)
ROM? (may have arthritis)
Strength/sensation? (affecting peripheral nerves)
Raynaud’s? (could affect pulse-ox readings)
Medications?
Meds that people with lupus may be on
1) Meds that affect coags
- Ibuprofen, indomethacin, ASA, COX-2 inhibitors, DVT preventative meds
2) Immunosupressants
3) Steroids
RA and the airway
1) TMJ arthritis- limited mouth opening
2) Atlanto-axial joint arthritis- get CT or MRI- get radiology to clear c-spine
3) Cricoarytenoid arthritis- hoarseness, painful swallowing, dyspnea, stridor, laryngeal tenderness
RA affects these systems
1) JOINTS
2) CV (ECHO and EKG if cardiac involvement)
3) Pulm (PFTs and ABG if restrictive lung involvement)
4) Neuro
In those with rheumatoid arthritis, dyspnea is often a sign of
cardiac ischemia
Meds that someone with MG is probably on
Cholinesterase inhibitors (try to limit NM blockade) Steroids (will need stress dose) Immunosuppressants
We should avoid this medication in muscular dystrophy
Succhinylcholine
- can cause fatal hyperkalemia or arrhythmia
- screen kids for s/s of muscular dystrophy in your pre-op
- avoid routine use of sux in kids
Considerations for marfan syndrome
Cardiopulmonary
- ECHO, high risk for PTX, check TMJ
Main joint we’re concerned about with ankylosing spondylitis
Sacroiliac
Considerations for ankylosing spondylitis
Joint ROM (especially sacroiliac), pain management, EKG, PFTs (checking for restrictive disease), medications (NSAIDs, methotrexate)
