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Advanced Principles A > Ortho > Flashcards

Ortho Flashcards

1
Q

osteoporosis is caused by these 3 things:

A

age-related (elderly)
post-menopausal
hypothyroidism

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2
Q

increased risk of fractures in elderly is due to these hormonal changes:

A

increased PTH & cortisol
decreased vit D3, growth hormone, & insulin-like growth factors

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3
Q

______ compression fractures are most common with falls in the elderly

A

LUMBAR

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4
Q

Pts on fosamax, actonel, boniva, or reclast should hint to what pathophysiology?

A

osteoporosis

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5
Q

Arthritic disorder that is associated with inflammation, pain in weight bearing joints, and sx that worsen throughout the day (evening stiffness):

A

OA - osteoarthritis

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6
Q

swelling/spurring of DISTAL interphalangeal joints

A

Heberden’s nodes

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7
Q

swelling/spurring of PROXIMAL interphalangeal joints

A

Bouchard’s nodes

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8
Q

When should OA pts stop taking glucosamine prior to surgery?

A

2 wks – inhibits plt aggregation/risk bleeding

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9
Q

Arthritic disorder associated with morning stiffness that improves with activity:

A

RA - rheumatoid arthritis

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10
Q

What lab values are elevated in the RA pt?

A

rheumatoid factor
anti-immunoglobulin antibody
C-reactive protein (CRP)
erythrocyte sedimentation rate (ESR)

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11
Q

When reviewing home medications, you notice your elderly patient is taking methotrexate (MTX), what should you start thinking?

A

RED FLAG –> elderly + MTX = think RA, positioning & airway issues

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12
Q

What medications should the RA patient receive preop?

A

pain –> NSAIDs, opioids
Stress dose 100mg hydrocortisone IV

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13
Q

Airway considerations for RA pts:

A

limited TMJ movement, narrowed glottic opening, & cricoarytenoid arthritis = awake fiberoptic intubation &/or regional anes

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14
Q

What are some preop Qs to ask your RA pt to assess possible difficult airway (prior to the physical exam)?

A

hoarseness in voice, dysphagia, stridor, neck tenderness

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15
Q

Atlantoaxial instability in RA involves what 2 vertebrae?

A

C1 - atlas
C2 - axis
** displaces odontoid process (dens)

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16
Q

atlantoaxial instability in RA pts can result in impingement/compression of the:

A

C-spine, medulla, & vertebral arteries

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17
Q

Symptoms of atlantoaxial subluxation:

A

HA
neck pain
Upper & lower extremity paresthesia with movement
bladder/bowel dysfunction

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18
Q

vertebral artery occlusion/compression symptoms:

A

N/V
dysphagia
blurred vision
transient loss of consciousness

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19
Q

Sjogren’s syndrome is associated with RA and results in:

A

dry eyes & mouth

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20
Q

An RA patient has what type of ventilation issues? (obstructive or restrictive)

A

RESTRICTIVE – d/t diffuse interstitial fibrosis

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21
Q

What is a safe vent setting for the RA patient per Dr. Castillo?

A

PC-Volume guarantee
Vt = 5ml/kg IBW

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22
Q

RA + elderly + NSAID use can result in:

A

gastric ulcers & renal insufficiency

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23
Q

What does MILS/MILI stand for?

A

manual in-line stabilization/immboilization

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24
Q

If pt is confused or uncooperative, then this type of anes is not appropriate:

A

neuraxial or regional

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25
Q

Stabilization of head, neck, & torso in neutral position for pts who have not been cleared by x-ray is referred to as:

A

MILS/MILI

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26
Q

What airway maneuver is acceptable in trauma/c-spine pts?

A

chin lift – results in slight c-spine movement, but is allowed to open up airway

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27
Q

How does aging affect FEV1?

A

FEV1 decreases 10% for each decade

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28
Q

What is the target HR for elderly?

A

< 80 bpm

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29
Q

Which NMB reversal agent is safest for elderly?

A

sugammadex – avoids the HR changes seen with neostigmine & glyco)

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30
Q

When do symptoms of FES start to present?

A

12-72 hrs after trauma or surgery

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31
Q

FES symptoms triad:

A

dyspnea + confusion + petechiae 12-72 hrs after trauma or surgery

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32
Q

Which triad symptoms is the most definitive finding of FES?

A

PETECHIAE - conjunctiva, oral mucosa, skin folds of chest, neck, & axilla

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33
Q

Normal SED rate male:

A

0-22 mm/hr

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34
Q

Normal SED rate female:

A

0-29 mm/hr

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35
Q

long bone trauma (femur) and pelvic fractures can commonly cause:

A

FES - fat embolism syndrome

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36
Q

best preventative management of FES:

A

early recognition
fracture stabilization/immobilization ASAP

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37
Q

FES symptoms can resolve in _____ if managed appropriately.

A

3-7 days

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38
Q

When can you perform neuraxial anes after a patient has received LMWH (once daily dosing)?

A

10-12 hrs after previous LMWH dose (if there is no indwelling catheter)

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39
Q

if LMWH is given twice daily dosing, what should you consider with neuraxial anes?

A

NO indwelling catheter — must remove 2+ hrs before next LMWH dose

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40
Q

How soon after a neuraxial block can a patient resume LMWH dose?

A

4 hrs

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41
Q

without prophylaxis, risk of thrombosis is ____%

A

40-80%

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42
Q

Neuraxial anesthesia is ok if a patient is on warfarin as long as the INR is:

A

1.5 or less

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43
Q

What are the 3 advantages of neuraxial anesthetics in preventing VTE formation?

A

increased lower extremity venous blood flow (d/t sympathectomy)
LA = systemic anti-inflammatory properties
decreased platelet reactivity

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44
Q

When can neuraxial block be performed after aspirin & NSAIDs are stopped?

A

no additional precautions with these 2 medications

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45
Q

When can neuraxial block be performed after CLOPIDOGREL (PLAVIX) is stopped?

A

5-7 days

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46
Q

When can neuraxial block be performed after PRASUGREL (EFFIENT) is stopped?

A

7-10 days

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47
Q

When can neuraxial block be performed after TICLOPIDINE (TICLID) is stopped?

A

10 days

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48
Q

When can neuraxial block be performed after TICAGRELOR (BRILINTA) is stopped?

A

5-7 days

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49
Q

When can neuraxial block be performed after CANGRELOR (KANGREAL) is stopped?

A

3 hrs

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50
Q

When can neuraxial block be performed after ABCIXIMAB (REOPRO) is stopped?

A

24-48 hrs

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51
Q

When can neuraxial block be performed after TIROFIBAN (AGGRASTAT) is stopped?

A

4-8 hrs

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52
Q

When can neuraxial block be performed after EPTIFIBATIDE (INTEGRILIN) is stopped?

A

4-8 hrs

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53
Q

When can neuraxial block be performed after DIPYRIDAMOLE (PERSANTINE) is stopped?

A

24 hrs for ER formulation

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54
Q

When can neuraxial block be performed after CILOSTAZOL (PLETAL) is stopped?

A

2 days

55
Q

Which antithrombotic agent is ok to give while indwelling neuraxial catheter is in place?

A

HEPARIN

56
Q

How long should APIXIBAN (ELIQUIS) be held prior to neuraxial procedures?

A

48 hrs

57
Q

What type of patients should TXA be avoided in?

A

hx of VTE events
recent coronary stents
severe ischemic heart dz
MI
CVA
renal impairment
pregnancy

58
Q

binds reversibly to plasminogen by its lysin-binding site, inhibiting its association with fibrin & inhibits the proteolytic activity of plasmin

A

TXA - tranexamic acid

59
Q

When should TXA be administered in an orthopedic case?

A

most commonly administered IV prior to incision (some providers like a continuous infusion throughout case, and some will like another bolus dose at end of case)

60
Q

Max dose of TXA?

A

2.5 g

61
Q

Variable IV dosing for TXA includes:

A

10 mg/kg
15 mg/kg
30 mg/kg
** common to give 1gm (the full 10ml syringe)

62
Q

The width of a pneumatic tourniquet should be:

A

1/2 diameter of entire limb

63
Q

How soon does tourniquet pain begin?

A

45 mins

64
Q

What can be done to help tourniquet pain?

A

REGIONAL ANES

65
Q

Tournique inflation pressures for thigh:

A

SBP + 100mmHg = inflation pressure

66
Q

Tourniquet inflation pressures for arm:

A

SBP + 50mmHg = inflation pressure

67
Q

Standard MAX time for tourniquet inflation:

A

3 hrs (180 min)
** generally not to exceed 2 hrs if possible d/t risk of nerve injury

68
Q

Prolonged tourniquet inflation issues > 2 hrs can result in:

A

NERVE INJURY

69
Q

Common upper extremity tourniquet inflation pressure?

A

~ 250 mmHg

70
Q

Common lower extremity tourniquet inflation pressure?

A

~ 300 mmHg

71
Q

What MUST the anes provider do when a tourniquet is being applied to a patient for an ortho case?

A

DOCUMENT ** even if OR nurse is already documenting it
- inflation time
- deflation time
- total inflated time
- inflation pressures & any adjustments

72
Q

How can nerve injury be minimized if tourniquet time is exceeding the max time (3 hrs)?

A

deflating tourniquet for 20-30 min to allow for reperfusion –> then surgeon can resume case

73
Q

Tourniquet pain is related to:

A

regression of neuraxial block –> unmyelinated C fibers firing

74
Q

Ortho patient has had a tourniquet inflated for 45-60 min and starts to have an increased HR & BP + diaphoresis. What might be going on?

A

TOURNIQUET PAIN d/t regression of neuraxial block & unmyelinated C fibers firing

75
Q

If a patient has a double tourniquet on a limb, what order should they be inflated & deflated?

A

inflate proximal
deflate distal

76
Q

What are some additional negative effects that can occur once tourniquet is deflated?

A

metabolic acidosis
hyperkalemia
hypercarbia
tachycardia
HTN
** all d/t cellular metabolites being released once limb is reperfused

77
Q

How can we treat the transient lactic acidosis & hypercarbia post tourniquet deflation?

A

Increase minute ventilation = blow off that extra CO2

78
Q

______ programs can be useful in geriatric patients to reduce frailty & improve surgical outcomes.

A

Prehabilitation

79
Q

Fractures of the ______ following falls are common in older patients & associated with high morbidity & mortality.

A

proximal femur

80
Q

This surgical position offers superior exposure & access for most shoulder surgeries, less anatomy distortion, & less tension on the brachial plexus.

A

BEACH CHAIR > lateral decubitus

81
Q

_____ can decrease by 15% in sitting patients (beach chair position) under general anesthesia.

A

Cerebral perfusion pressure (CPP)
** normal CPP = 60-80 mmHg

82
Q

Intraop hypotension, hypoxia, & even cardiac arrest can occur following cemented fixation of the femoral prosthesis, this is known as:

A

bone-cement implantation syndrome

83
Q

How should we manage bone-cement implantation syndrome?

A

potent inotropic agent – epi
invasive hemodynamic monitoring – art line & maybe CVP
** pulsatile lavage of femoral canal & drilling vent hole in femur before prosthesis can avoid the hemodynamic consequences

84
Q

____ is probably the single most important cardiac risk factor in orthopedic patients.

A

CAD

85
Q

The Doppler Ultrasound transducer is a sensitive non-invasive indicator of a venous air Embolism (VAE) in the sitting patient. Where do you place the probe on the chest?

A

over the right atrium - 2nd ICS @ right sternal border

86
Q

For every cm distance between brain & heart, there is a ______ mmHg decrease in BP

A

0.77 mmHg

87
Q

Normal distance between top of brain & heart:

A

10-30 cm

88
Q

if cuff is 30 cm below the top of the brain & pts BP is 90/60, what is the approx. BP at top of the brain?

A

0.77 x 30cm = 23
90-23 / 60-23 = 67/37 mmHg

89
Q

Induced hypotension is sometimes used in shoulder surgery to prevent bleeding and provide the surgeon with a better view, but this can lead to:

A

Retinal Ischemia
Ischemic Optic Neuropathy

90
Q

cardiac inhibitory reflex that leads to hypotension + bradycardia R/T venous pooling (decreased preload) & hypercontractile ventricle (Decreased intraventricular volume)

A

Bezold-Jarisch Reflex

91
Q

Most definitive treatment for venous air embolism (VAE)

A

Withdrawing air through a previously placed right atrial catheter/CVC

92
Q

most sensitive non-invasive indicator of VAE

A

Placement of a doppler ultrasound transducer at the second or third intercostal space to the right of the sternum (over the right atrium)

93
Q

Most definitive indicator of VAE?

A

TEE

94
Q

a “mill-wheel” murmur is a characteristic sound of

A

VAE - venous air emobism

95
Q

What actions can you take if a venous air embolism is suspected in your patient?

A

Placing the patient in a head-down position (to trap the air in the RA apex preventing entrance to the PA)
**Withdrawing air through a previously placed right atrial catheter/CVC

96
Q

During elbow surgery, a spontaneously breathing patients dependent lung will have:

A

NO V/Q mismatch
** mech ventilation = V/Q mismatch in the dependent lung

97
Q

If a patient has an axillary roll in place, where should the pulse be put on?

A

in the dependent hand
**periodically check radial pulse

98
Q

For elbow procedures, tourniquets are typically inflated to:

A

100 mmHg > SBP

99
Q

What lower extremity surgeries are considered emergent/urgent procedures?

A

hip fractures ORIF

100
Q

How do you establish NPO time for a hip fracture patient?

A

gastric motility stops at “trauma” time so NPO time starts from the time the patient last ate to the time of trauma

101
Q

Common complication in the sitting/beach chair position?

A

VAE - venous air embolism

102
Q

If the surgical site is higher than the heart, then what can occur?

A

potential to entrain room air into open vessels and cause VAE

103
Q

Ventilatory changes of the dependent lung on mechanical ventilation:

A

dependent (down) lung is underventilated d/t compression by the weight of the mediastinum & abdominal contents

104
Q

ventilatory changes of the non-dependent (up) lung on mechanical ventilation:

A

non-dependent lung is overventilated b/c its compliance is increased

105
Q

_____ causes pulmonary blood flow to favor the ______lung

A

GRAVITY
dependent lung

106
Q

Ortho procedure that you should be prepared to potentially give blood transfusions?

A

hip fracture - ORIF
** large amt of extravasated/occult blood because its a closed fracture inside pt

107
Q

Which physics law is responsible for IVF flow rate gravity drip?

A

Poiseulle’s Law
**increase ht of table = lose gravity drip of IVF = slower flow

108
Q

3 potential life threatening complications of total hip arthroplasty (THA)?

A
  • bone cement implantation syndrome (BCIS)
  • intraop & postop hemorrhage
    -VTE
109
Q

Name of cement placed in acetabular & femoral stem in THA?

A

PMMA - polymethylmethacrylate

110
Q

Cement used in total hip replacements can result in:

A

intramedullar HTN
** increases up to 500 mmHg d/t exothermic reaction (heat release)

111
Q

Systemic absorption of fat emboli in venous circulation results in:

A

vasodilation = decreased SVR

112
Q

Prepare to give _____ once surgeon starts cementing in total hip arthroplasty.

A

pressors – ephedrine or neo
** helps prevent BCIS

113
Q

hypoxia, hypotension, arrhythmia’s, pulm HTN, decreased CO during total hip arthroplasty are a result of:

A

BCIS - bone cement implantation syndrome

114
Q

List most common complications of total hip arthroplasty:

A

cardiac events
PE
pneumonia
respiratory failure
infection

115
Q

When supine in a hip arthroscopy, what happens to your FRC?

A

decreases

116
Q

To prevent ulnar nerve injuries when supine, how should the hands be positioned?

A

palms up (supinated)

117
Q

The most common postoperative peripheral neuropathy is:

A

Ulnar neuropathy

118
Q

Hip dislocation requires:

A

closed reduction internal fixation = no incision

119
Q

Anesthesia mgmt for hip dislocations:

A

may be performed in ER or PACU, emergent - so have emergent equipment & anes cart ready.

Conscious sedation - ketamine & propofol pushes with succinylcholine for muscle relaxation + mask ventilation

120
Q

For complete analgesic knee coverage, what regional blocks should be performed for a total knee arthroplasty?

A

femoral + sciatic nerve block

121
Q

4 Artificial Components of the knee

A
  • Tibial component
  • Femoral component
  • Patellar component
  • Plastic spacer
122
Q

Total knee arthroplasty’s are very painful postop, what’s the preferred and best pain mgmt option for this patient?

A

spinal with duramorph (morphine)

123
Q

Neuraxial anesthesia is preferred in amputations because it results in:

A

less phantom limb pain

124
Q

When does phantom limb pain onset occur post amputation?

A

within a few days of surgery

125
Q

Phantom limb pain triggers:

A

weather changes
emotional stress
pressure on remaining area

126
Q

What are some treatment medications used for phantom limb pain?

A

neuroleptics (antipsychotics)
antidepressants
Na channel blockers

127
Q

When a patient receives an ankle block, what are the 5 nerves involved?

A

Posterior tibial nerve  Sensation to plantar surface

Saphenous nerve  Innervates medial malleolus

Deep peroneal nerve  Interspace b/t great & 2nd toes

Superficial peroneal nerve  Dorsum of foot & 2nd – 5th toes

Sural nerve  Lateral foot & lateral 5th toe

128
Q

Ankle block: Posterior tibial nerve provides sensation to

A

plantar surface (bottom of heel/foot)

129
Q

Ankle block: saphenous nerve innervates

A

medial malleolus

130
Q

Ankle block: deep peroneal nerve innervates

A

intersepace between great & 2nd toes

131
Q

Ankle block: superficial peroneal nerve innervates

A

dorsum (top) of foot & 2nd-5th toes

132
Q

Ankle block: sural nerve innervates

A

lateral foot & lateral 5th toe

133
Q

Which arthritic disorder is generally NOT associated with thoracolumbar spine involvement?

A

RA - rheumatoid arthritis

Advanced Principles A (2 decks)

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