Ortho Flashcards by Mary Munoz

Osteoporosis risk factors (2)

Age related
Post menopausal (women)
Increased risk for fractures

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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

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Meds that help osteoporosis (4)

Fosamax, Actonel , boniva, reclast

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Osteoarthritis pathology

Loss of articular cartilage -> inflammation = pain
Usually weight-bearing joints (knee/ spine/ neck/ hips, shoulders)

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Risk factors for osteoarthritis

Age > 65

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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.

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What percent of osteoarthritis pts experience physical limitations

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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

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What is glucosamine?

A natural compound found in cartilage.

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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

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Rheumatoid arthritis pathophysiology

Chronic and systemic inflammatory disease
Joint synovial tissue/ connective tissue inflammation leads to;

Bone erosion
Cartilage destruction
Impaired joint integrity

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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

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Labs to diagnose RA

Increased;
Rheumatoid factor,
antiimmunoglobulan antibody,
CRP,
Erythrocytes sedimentation rate

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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.

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Stress dose steroids

50 mg of solucortef hydrocortisone

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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)

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Axis and atlas

C1= atlas
C2= axis

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Vent mode for pts with restrictive lung dz

pressure controlled and volume guaranteed to ensure not over-inflating the lungs

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Intervention for atlantoaxial subluxation symptoms

Evaluate c-spine flexion & extension x-rays

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Vt set range for rheumatoid arthritis

5 ml / kg

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Vertebral artery occlusion symptoms from RA

N/v
Dysphasia
Blurred vision
Transient LOC

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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.

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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

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