CCFP Medley

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CCFP Medley

• Rheumatological Emergencies
• Vavular HD Endocarditis
• Spinal s

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Rheumatology in the Ed

• Acute Joint
• Septic arthritis
• Septic bursitis
• SLE in the ED
• RA in the ED

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Acute Painful Joint

• Periarticular?
• Bursitis, tendonitis, cellulitis
• Mono or Polyarticular?
• Mono needs to be sorted in out ED
• Septic, gout, pseudogout, OA, trauma,
  hemarthrosis, gonococcal
• Polyarthritis
• Admit Med if systemically unwell, Rheum triage
  for urgent referral if can go home

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Septic arthritis

• Acute monoarthritis is septic until proven
  otherwise

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Who is at risk for SA?

• immunocompromised
• RA and other inflammatory arthritis (including
  gout)
• Prosthetic joints
• IVDU

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Clinical Features

• Knee gt hip gt shoulder gt wrist gt ankle gt elbow
• 20 afebrile on presentation
• Pain is remarkable and limitation of ROM
  significant unless prior Abx

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Diagnostic Testing

• WBC
• 15 not elevated in septic
• ESR/CRP
• No discriminatory value
• Uric acid level
• May be normal in acute gout or elevated in septic
  arthritis
• Blood Cultures
• Arent back in the ED
• Only 50 positive

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Arthrocentesis in SA

• Arthrocentesis essential
• Thin, turbid
• Cell count 5000 - gt 50000
• Only 50-70 gt 50000
• gt75 PMNs
• Glucose lt 50 serum
• GS positive in 50-70
• If unclear, ortho opinion, admit, cover with Abx
  until BC return

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Pitfalls in Synovial Fluid Interpretation

• Early
• Previous antibiotics
• Immunosuppressed
• Synovial WBCs 2000-5000 not uncommon

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Septic Bursitis

• Olecranon and prepatellar common
• Difficult distinction
• When septic usually peribursal swelling and
  erythema /- cellulitis
• No standardized approach
• Aspiration if concerned
• WBC gt 5000 likely septic
• Septic? ID, IV Abx, F/U HPTP
• Indeterminate? Oral Abx, F/U

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SLE in the ED
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SLE in the ED

• Fever
• Immunocompromised
• Neuro
• Seizures
• CVA
• Psychosis
• Lupus cerebritis
• CT head, LP R/O meningoencephalitis
• Bacterial, fungal, TB, brain abscess all possible

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SLE in the ED

• Cardiac
• Pericarditis
• Effusions usually benign
• Myocarditis
• Common, usually little clinical manifestation
• CAD
• Increased prevalence

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SLE in the ED

• Pulmonary
• Pleural effusions
• PE
• Oppurtunistic infections
• Lupus pneumonitis (Dx of exclusion)
• Chest pain/dyspnea in the SLE patient very
  serious complaint

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SLE in the ED

• NSAIDS may worsen lupus nephritis

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RA in the ED

• Fever
• Immunosuppressed
• Acute joint
• Do not dismiss monoarthritis as RA flare
• Think septic joint first
• They know their disease

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RA in the ED

• Cardiac
• Increased predisposition to CAD
• Unclear
• chronic inflammation, steroids accelerating
  atherosclerosis, vasculitis
• Pericarditis/pericardial effusions in _at_40 of
  patients
• Neuro
• Nerve entrapment and neuritis common

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RA in the ED

• Trauma
• Neck pain neuro signs
• Rupture of transverse ligament, displacement of
  odontoid

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Blood Culture Result

• July 1st
• Abnormal lab result
• Single BC coag negative staph?
• Single BC Staph aureus?

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Infective Endocarditis (IE)

• Prosthetic HV
• IVDU
• PHx endocarditis
• Rheumatic or CHD
• Calcific degenerative valve dz
• MVP

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Clinical Features

• Very nonspecific (viral)
• Think in repeated visit for fever NYD
• Early, often no murmur
• IVDU often no murmur
• 30-40 some central neuro symptoms
• 30-40 peripheral cutaneous findings

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IE Clinical Suspicion
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IE Clnical Suspicion
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IE Clnical Suspicion
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IE Clnical Suspicion
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IE Diagnostic Work-up

• Lab findings nonspecific
• Leukocytosis lt50
• 3 sets of BCs
• 1st and last 1 hour apart
• 90-95 positive unless prior Abx
• TEE vs TTE

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IE Diagnostic Criteria

• Duke Criteria
• 2 major or 1 major/3 minor or 5 minor
• Major
• BC from at least 2
• ECHO evidence
• Minor
• Predisposition
• Fever
• Stigmata (cutaneous, conunctival etc.)
• Single BC
• ECHO abnormal not meeting criteria

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IE Management

• Febrile prosthetic valve patients or persistent
  fever in IVDU - err on admission
• Vanco Gent
• Ceftriaxone Gent

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Quick Case

• 67m, acute CP, SOB
• Looks unwell, clinically CHF
• III/VI murmur at apex
• ECG acute anterior MI

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Acute Valvular Rupture

• Acute MVR
• Flash pulmonary edema
• MI pulm edema MR murmur
• no ECG evidence of LVH/LAE
• Tx CHF normally, STAT ECHO, cath and IABP,
  contact CV Surgery

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Severe AS

• CHF exertional syncope
• Tenuous pre/afterload balance
• 1cm/50mmHg
• Medication change?
• Gentle fluid resus if hypotensive
• Cardiology admission
• Assess if surgical candidate

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Quick Case

• 70f, AoVR, near-synopal at home
• Hypotensive, CHF

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Prosthetic Valve

• Type, location, age
• Ask for surgical card
• Almost all some degree of narrowing
• mild systolic murmur common
• Diastolic murmur always abnormal
• failure

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Acute Valvular Failure

• Hypotension new onset CHF in patient with known
  prosthetic valve
• Leaflet failure in bioprosthetic
• Thrombosis of mechanical valve
• STAT TTE, cardiology and CV surgery
• Anticoagulation if thrombosed, some advocate
  thrombolyzed

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Valvular Emergencies

• IE
• Rupture of native valve
• Critical AS
• Acute failure of prosthetic valve
• Thrombosis
• Mechanical breakdown
• Embolization
• Debris, clot, actual valve structure
• Hemolysis

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Thoracic s

• If suspicious for in T1-T5, often need CT scan
• Swimmers useful
• Spinal canal narrowest in T spine
• Retropulsion common
• Low threshold for further imaging

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Lumbar Spine s

• Very common
• Wedge compression
• Loss of 25-30 ant height necessitates CT scan
• Compression burst
• Retropulsion common
• Always CT

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Summary

• Rheum
• Acute painful joint,
• Septic Arthritis
• SLE in ED
• RA/CTD in ED
• Spine s
• Review critical C spine s
• T and L spine s
• Valvular Emergencies
• IE
• Acute MV rupture critical AS
• Prosthetic valve problems