Ortho Flashcards
Osteoporosis risk factors (2)
Age related
Post menopausal (women)
Increased risk for fractures
Causes of osteoporosis (2)
1)Increased parathyroid hormone
2)Decreased vitamin D, growth hormone and insulin- like growth factors
3) Stress fractures; Compression fractures of the lumbar/ thoracic or Proximal femur & humerus & wrist
Meds that help osteoporosis (4)
Fosamax, Actonel , boniva, reclast
Osteoarthritis pathology
Loss of articular cartilage -> inflammation = pain
Usually weight-bearing joints (knee/ spine/ neck/ hips, shoulders)
Risk factors for osteoarthritis
Age > 65
S/S of osteoarthritis (4)
-Pain
-Creditance; grating sound caused by friction
-Decreased mobility; activity level declines as the day progresses because of the pain
-Joint deformity; Heberdon nodes (distal interphalangeable joints). Bouchard nodes (proximal interphalangeal) joints.
What percent of osteoarthritis pts experience physical limitations
8%
Meds/ treatment for osteoarthritis
NSAIDs; Meloxicam
Celebrex; cox 2
opioids
Topical treatment; diclofenac (Voltaire’s; NSAID OTC)
Intraarticular therapy; steroid injections
Chondroprotective agents; Glucosamine
Occupational therapy
Wt loss
Acupuncture
TENS; transcutaneous electrical nerve stimulation
What is glucosamine?
A natural compound found in cartilage.
When should herbal medications be stopped before sx and what do they affect?
Stop 2 weeks before sx and they affect plat aggregation
Glucosamine/ ginger, ginko
Rheumatoid arthritis pathophysiology
Chronic and systemic inflammatory disease
Joint synovial tissue/ connective tissue inflammation leads to;
Bone erosion
Cartilage destruction
Impaired joint integrity
S/S of RA
1)Multiple joints involved; wrist and metacarpophalangeal joints
2)Pain, stiffness
* morning stiffness
3) Anorexia, fatigue, weakness
4) Sub q (rheumatoid) nodules surround joints, extensor surfaces, and bony prominences
Labs to diagnose RA
Increased;
Rheumatoid factor,
antiimmunoglobulan antibody,
CRP,
Erythrocytes sedimentation rate
Meds for RA
Glucocorticoids; stress Dose
NSAIDS
Opioids
Methotrexate (antineoplastics)
Hydroxychloroquine (antimalaria immunosuppressive)
Sulfasalazine (DMARD)
Leflunomide (DMARD)
Infliximab (Remicade) IgG monoclonal antibody. inhibit TNF alpha.
Etanercept (Enbrel) TNF alpha inhibitor.
Stress dose steroids
50 mg of solucortef hydrocortisone
RA anesthesia concerns
Airway; limited TMJ movement (Temporomandibular joint)
Narrowed Glotic opening; smaller tube?
Circoarytenoid arthritis
Pain on swallowing
Strider
Tenderness of the larynx
Atlantoaxial instability; displace odontoid (dens) process -> impingement of spine and medulla
Vertebral artery compression
Atlantoaxial subluxation; x ray. HA, neck pain, up and LE parenthesis w/ movement, bladder/ bowel dysfunction.
Sjorgens syndrome (dry eyes/ mout)
Diffuse interstitial fibrosis
Restrictive ventilation pattern
Vascultitis/ pericarditis
Cardiac tamponade
Gastric ulcers
Renal insufficiency (age or nsaid use)
Axis and atlas
C1= atlas
C2= axis
Vent mode for pts with restrictive lung dz
pressure controlled and volume guaranteed to ensure not over-inflating the lungs
Intervention for atlantoaxial subluxation symptoms
Evaluate c-spine flexion & extension x-rays
Vt set range for rheumatoid arthritis
5 ml / kg
Vertebral artery occlusion symptoms from RA
N/v
Dysphasia
Blurred vision
Transient LOC
Ortho injury anesthesia concerns
Hemorrhage, shock, fat embolism
Full stomach d/t emergent nature of the fixation/ repair
Pelvic fractures -> iliac artery-> retroperitoneal space bleeding
Long bone fix -> bone marrow fat -> venous circulation -> thromboembolic-> hypoxia respiratory failure.
ABCD’s of trauma anesthesia
GETA; aspiration vs hypoxia
RSI
Preoxygenation
Circoid pressure; Sellick maneuver (10 lbs or 30 newtons)
Induction meds; ketamine/ etomidate
Muscle relaxation; sux/ roc
Apneic ventilation (Boyles law) or modified RSI
DL after 3 attempts -> combtitube or LMA
What is the other name/ pressure for cricoid pressure?
Cricoid Pressure, aka Sellick Maneuver (10 lbs or 30 Newtons)
Boyles law
pressure and volume of a gas have an inverse relationship
MILS
Manual in line stabilization
For head and neck in neutral position when pt not been cleared
Stabilize head and neck w/ no cephalad traction
Intubation
Stabilize shoulder
3 clinicians; shoulder, intubation, stabilize head
No jaw thrust, chin lift, and head tilt do restyles in c spine movement
Risk factors for ortho surgery
age > 85 yo
ETOH (consider cyp450)
Preop dementia/ cognitive impairment (dont do neuraxial)
Fev1 decreases by……
Fev1 decreases by 10% / decade
Triggers for delirium
Hypoxemia, hypotension, hypercarbia, sleep deprivation
Hypervolemia(dilutes electrolytes) , infection
Abnormal e-lytes
Pain
Administration of benzos & anticholinergics
Age related concerns for Respiratory status
decrease paO2
increased closing volume
FEV1 decreases by 10%/ decade
Obesity
OSA (stop Bang)
Target HR
Continue beta-blockers
Initiate beta-blockers if high risk
Target HR < 80 bpm
Fat emboli concern intra op, triad s/s, and labs
Common in pelvic and femoral fax
Long bone trauma -> release of fat droplets into the venous system
Fx releases mediators affecting the solubility of lipids in circulation
Symptoms in 12-72 hrs.
Triad; dyspnea, confusion, petechiae. Treat with increasing BP
Labs; fat macroglobinemia. Anemia and thrombocytopenia. Elevated Sed rate.
stop bang
Snoring
Tired
Observed stoping breathing
High blood pressure
BMI> 35
Age over 50 \neck circum
Gener; male?
What is fat metabolized to
free fatty acids
Normal SED rate male
0-22mm/hr
Normal SED rate female
0-29 mm/hr
Treatment of FES
Stabilize fracture
100% o2 , no n2o
Increased bp
Heparin IV
When do FES symptoms resolve
3-7 days
DVT medication prophylaxis
LMWH; 12 hrs preop or 12 hrs post op
IV or SQ heparin
LMWH in Neuraxial ok to do 10-12 hrs after previous dose. Delay next dose 4 hrs
warfarin; Neuraxial okay if INR </ = 1.5
DVT prophylaxis if the neuraxial catheter is not okay
remove catheter 2+ hrs before 1 st dose
Once catheter removed = delay 2 more hours before doing the LMWH
Surgeries at greatest risk for DVT/PE
Hip surgery
TKA
Lower extremity trauma
risk factors for DVT/ PE
Obesity
Age > 60 yo
Procedure length > 30 mins
Use of tourniquet
Lower extremity fractures
Immobilization > 4 days
Without prophylaxis: occurs 40-80%
Warfarin considerations for DVT prophylaxis and neuraxial anesthesia
Neuraxial anesthetic okay if INR < / = 1.5
TXA max
2.5 gm
Normal dosing; 10-30mg/kg
Concerns for TXA
Risk of VTE ?
Risk of MI, CVA, TIA ?
Many postop CV complications R/T anemia & blood transfusion
When to stop plavix prior to neuraxial
5-7 days
Width of tourniquet
> 1/2 diameter of the entire limb
What is an esmarch
Exsanguination
Increase blood volume into central circulation.
Advantages of doing a neuraxial with a pt that’s at risk for DVT
Increased lower extremity venous blood flow d/t sympathectomy
Systemic anti-inflammatory properties of local anesthetics
Decreased platelet reactivity
When does tourniquet pain begin?
After 45 min of being up
Tourniquet Pain begins after 45 mins: Regional Anesthesia supplement
Tourniquet inflation pressures and time
Thigh 100 mmhg > SBP
Arm 50 mmhg > sbp
UE 250 mmhg
LE 300 mmhg
Generally not to exceed 2 hrs. Max time 3 hrs = 180 min,
What to document for tourniquet
Inflation time
Deflation time
Total inflation time
Inflation pressure and any adjustments
Risk of tourniquet > 2 hrs
Nerve injury
Risk of ischemia and rhabdomyolysis
Mechanical trauma
After 3 hrs; Mini is risk by delaying tourniquet 20-30 minutes to allow for reperfusion then can reinflate after 30 min
Double tourniquet technique
Inflated proximal then deflate the distal
What causes the pain from the tourniquet
Tourniquet time/ malposition or pressure
Anesthesia technique
Dermatomal spread/ peripheral nerve coverage
Local anesthetic and dose (density)
Effects seen after deflation of the tourniquet
Metabolic acidosis
Hyperkalemia
Hypercarbia; lactic acid
Tachycardia and htn
Pain relieved
Decreased cvp, bp and temp
Transient lactic acidosis
Transient hypercarbia
Increased Minute ventilation
