Orthopedic Fractures

Question 1

With a trohanteric and subtronanteric fracture, how much blood are you expecting to lose?

Answer 1

1200 mL

Question 2

How do you treat a trohanteric and subtrohanteric fracture?

Answer 2

Screws into the leg with side plates

Question 3

What happens in a intrascapular hip fracture?

Answer 3

Bleeding into hip 800 mL
Slow healing with increased risk of aseptic necrosis but lower mortality rate

Question 4

What are some General anesthetic considerations for hip surgery?

Answer 4

Supine or lateral position
General v. RA + MAC
Monitoring –> consdier arterial line
Managing blood loss
Risk for thromboembolic event

Question 5

What is the treatment for a inter scapular hip fx?

Answer 5

Screws –> Austin Moore

Question 6

With any hip fracture, what should you be asking your patient?

Answer 6

What caused the injury –> MVC, Fall, ETC

Fall –> What precipitated the fall

MVC –> any additional injuries?

Question 7

In a total hip arthroplasty, what is the order of events?

Answer 7

1. hip is dislodged and femoral head is removed
2. acetabulum is enlarged preparing for the prosthesis
3. Acetabular prosthesis is held in place with two screws
4. Femoral prosthesis is placed

Question 8

What happens in a total knee arthroplasty?

Answer 8

Supine position
Spinal, epidural or GA

Femoral or Psoas + Sciatic Blocks

Intraarticular pain management

Question 9

Why does intra-articular pain management improve outcomes?

Answer 9

Decreased level of pain
Earlier PT
Decreased N/V
Earlier discharge
Decreased GI disturbance
Earlier extubation
decreased delirium
Increased revenue (increased # of pt seen in a day)

Question 10

With a spinal anesthetic, how long do you need to be off of Plavix for needle placement?

Answer 10

7 days

Question 11

With a spinal anesthetic, how long do you need to be off of Coumadin for needle placement?

Answer 11

Normal INR 1.4 after 5 days

Question 12

With a spinal anesthetic, how long do you need to be off of NSAIDS for needle placement?

Answer 12

No delay

Question 13

With a spinal anesthetic, how long do you need to be off of Ticlid for needle placement?

Answer 13

14 days

Question 14

With a spinal anesthetic, how long do you need to be off of Xalerto and Rivaroxaban for needle placement?

Answer 14

3 days

Question 15

What is scoliosis?

Answer 15

A deformity of the spine resulting in lateral curvature and rotation of vertebrae and deformity of rib cage

Question 16

When is surgical correction of scoliosis considered?

Answer 16

COBB angle >50%

Question 17

What is the goal with surgery for scoliosis?

Answer 17

Stop cardiac and respiratory compromise associated with curves

Question 18

What are the major anesthetic considerations related to positioning of a lumbar laminectomy?

Answer 18

Chest wall and abdominal compression decreases respiratory and venous return leading to decreased preload
Prone = decreased R heart filling pressures resulting in decreased BP and/or HoTN
POVL
Blood loss increased
Venous Air embolism

Question 19

What does a venous air embolism look like?

Answer 19

Increased EtNO2
HoTN
Mill Wheel Murmur

Question 20

How do you treat a venous air embolism

Answer 20

Wound irrigation with saline
N2O D/C
Vasopressor
Aspiration of air from CVP if in place
Lay patient right side up

Question 21

How can you decrease the need for blood transfusion?

Answer 21

Use of tourniquets (if appropriate)
Controlled HoTN
Preopeative HBG optimization with Iron and erythropoietin
Autologous blood donation
Acute normovolemic hemodilution
Cell Saver
TXA

Question 22

What is acute normovolemic hemodilution?

Answer 22

blood taken off and replaced with crystalloid or colloid just before incision –> allows for infusion of pt own blood when needed and bypasses errors with blood bank

Question 23

What is a cell saver?

Answer 23

Saves blood and divides it up
Requires another person
CANNOT BE DONE WITH CANCER

Question 24

What is TxA?

Answer 24

Transexamic acid

Antifibrinolytic therapy
inhibits clot breakdown by reducing the binding of plasminogen to fibrin

Question 25

What is the patho of a Fat embolus?

Answer 25

occurs with insertion of prosthesis, reduction of joint or tourniquet deflation

Anticipate prior to bone cement

Associated with multiple traumatic injuries and surgeries of long bones

Fat globules lodge in pulmonary vasculature resulting in obstruction of pulmonary circulation
Fat globules are hydrolyzed into free fatty acids that are directly toxic to the pulmonary endothelium and pneumocytes resulting in
- Endothelial damage
- Platelet Adhesion with clot formation
- Capillary leakage and perivascular bleeding

Question 26

What are some common s/sx of Fat Embolism Syndrome?

Answer 26

Pulm distress
AMS
Petechial Rash
Decreased PaO2
Elevated CRP
CV collapse

Question 27

What is the treatment for fat embolic

Answer 27

Hydration
Vasopressors for HD support
Increase FiO2
Steroids to reduce inflammatory response

Question 28

What is Bone Cement implantation syndrome?

Answer 28

due to fat emboli and debris from the intramedullary canal of long bones during manipulation, reaming and cementing

Question 29

What are some s/sx of bone cement implantation?

Answer 29

Fever
Tachycardia
Hypoxemia
Dyspnea
Tachypnea
HoTN
Low ETCO2
Right axis deviation
RBBB
RV FAILURE AND CARDIAC ARREST

Question 30

What is the treatment for bone cement implantation syndrome?

Answer 30

Fluids, Maximize FiO2, Inotropes/pressors, No N2O

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