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Rheumatolgic Emergencies

Rheumatolgic Emergencies. Conflicts. None Errors - Mine. Thanks to: Dr. Walker Dr. Hadley Dr. Del Castilho. Table of Contents. What is that!? What unites them all? Questions/Discussion. (knee). Acute Monoarthritis. Inflammatory Crystals Bacteria Rheumatiod Arthritis

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Rheumatolgic Emergencies

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  1. Rheumatolgic Emergencies

  2. Conflicts • None • Errors - Mine. • Thanks to: • Dr. Walker • Dr. Hadley • Dr. Del Castilho

  3. Table of Contents • What is that!? • What unites them all? • Questions/Discussion

  4. (knee)

  5. Acute Monoarthritis • Inflammatory • Crystals • Bacteria • Rheumatiod Arthritis • Spondyloarthropathy • SLE • Sarcoidosis • Bursitis • Non-Inflammatory • Trauma • HbS • Osteonecrosis

  6. Acute Monoarthritis • Septic joint in RA – overlooked • Delay of Dx 1-3 weeks • Significant joint damage • Mortality 20 - 33%

  7. Acute Monoarthritis • What blunts identification? • Often insidious onset • 'Unrewarding physical exam' • Absence of fever 50% • Polyarticular pattern in 25% of pts • Immunosuppression • Plausible reason for red, sore knee

  8. Red and Hot • 'The most important laboratory test in evaluating monarticular joint pain is synovial fluid analysis.' UTDOL.

  9. WBC not enough

  10. What to order • Look at it • Xantho, clear, cloudy, purulent • Total leukocyte count and diff • Gram stain and culture • Crystals (polarizing micro) • Glucose

  11. WBC not enough

  12. Tx • Depends on most likely cause • No RTC of ABx in septic arthritis • Red knee, no infection • Intraarticular steroids • Polyarthritis – increase oral steroid, control flare

  13. http://www.medscape.com/viewarticle/706761

  14. http://www.medscape.com/viewarticle/706761

  15. Ankylosing Spondylitis • Pathologically rigid spine becomes osteoporotic • ~10% # c-spine in lifetime • Neuro complications common • 2/3 may not completely recover Neurologically. Unstable fracture through disc space C6/7

  16. Ankylosing Spondylitis • Most common presentation: • Pain, usu localized. • Aggravated by movement. • Different from inflammatory pain of AS. • Mass effect: • Bleeding and edema • May present as radiculopathy and myleopathy.

  17. Ankylosing Spondylitis • MC Site? • C6-7 • How is it missed? • Not considered. • Plainfilm XR • No Hx major spinal trauma 50%! • Nature of #: • Often non-displaced • Small size (Syndesmophytes)

  18. C5-C6 • Inverted radial reflex

  19. Predicted Problems

  20. Ankylosing Spondylitis • When to order Imaging? • If pain is new, out of ordinary. • Neurologic complaints or findings. • XR, CT +/- MRI • What to do? • Cautious immobilization. • Ortho.

  21. Sceroderma

  22. Sceroderma

  23. Scleroderma Renal Crisis • ~10-20% develop it. • ~20% mortality. • ~20% will need HD after crisis.

  24. Scleroderma Renal Crisis • How to identify it? • Acute onset renal failure, progressive azotemia. • New HTN (from normal to malignant). • >150/85 2x/24hrs, mean peak 178/102. • Headache • Microangiopathic anemia c thrombocytopenia • Urine – normal or mild prot c cells or casts • +/- Flash pulmonary edema

  25. Scleroderma Renal Crisis • Steroids?

  26. Scleroderma Renal Crisis • What to do? • ACEi (Grade 1A). • Captopril (Grade 2B) – no CNS s/s. • Add Nitroprusside – WITH CNS s/s. • Nephro.

  27. Giant Cell Arteritis • Granulomatous arteritis of thoracic aorta and its branches. • Classic symptoms: • Usu >50, new headache, tender scalp, fluctuating vision, jaw claudication, constitutional symptoms. • Temporal artertis • Prednisone 60 mg/d biopsy within 1 week • Polymyalgia Rheumatica

  28. Lit review up to 2004 • 23 studies, 2036 pts, 5 languages. • May be helpful, caution with test results. • The future

  29. Giant Cell Arteritis- Vetebro-Basilar Insufficiency • TA + new defects of vetebro-basilar territory • Untreated – risk of bilateral vetebral artery occlusion, mortality 75%. • ESR • MR angio • Tx: high dose steroids • ??OTHER vertebral angiogram

  30. Giant Cell Arteritis- Aortitis • GCA – 27% pt large artery complications. • Ascending aortic aneurysms 17x • AAA 2.5x • Suspect it • Hx, RF • CT / MRI

  31. Instability of C-Spine • 71% of pts with RA have C-spine involvement • 70% may have subluxation • 25% of these -> frank dislocation • 11% cord compression • 5 yr survival – 80% • 10 yr survival - 28%

  32. Atlantoaxial subluxation • MCC: Neck/occiput/forehead pain in RA? • Atlantoaxial subluxation • MCC: • Atlantoaxial subluxation ~70% • Synovium of C1-C2 articulation • Synovial C2 – Transverse ligament articulation • Subaxial subluxation ~20% • Synovium below C2 Decision making in spinal care  By Alexander R. Vaccaro, D. Greg Anderson

  33. Atlantoaxial subluxation • Anterior atlantodens interval • McRae's Line • McGregor's Line

  34. Atlantoaxial subluxation

  35. Atlantoaxial subluxation • General Precautions? • Suspect it: RA pt with new onset occipital pain and/or tingling of fingers. • Caution with Passive flexion of C-Spine. • Caution with intubation. (Stabilize) • When to order Flex/Ex? • What to do if >3.5mm ADI?

  36. Adrenal Insufficiency • What unites most rheumatic diseases? • Steroid dependence • Can be • Medical or surgical stress • Stopping of Rx • S/S • Hypotension, lethargy, change to mental status, hypoGlc.

  37. Adrenal Insufficiency • Tx • NS • Glc • Hydrocortisone 100 mg IV • Or: (dexamethasone 4 mg IV – no impact on ACTH test or cortisol level)

  38. Questions • Bibliography • Adam: Grainger & Allison's Diagnostic Radiology, 5th ed • Barr, W et al. Principles of Critical Care - 3rd Ed. (2005), Ch 104 • Current Diagnosis & Treatment in Orthopedics - 4th Ed. (2006) • Firestein: Kelley's Textbook of Rheumatology, 8th ed. • Fotini B. Karassa et al. Meta-Analysis: Test Performance of Ultrasonography for Giant-Cell Arteritis. Ann Intern Med. 2005;142:359-369. • Ginsberg Lawrence E, "Chapter 13. Imaging of the Spine" (Chapter). Chen MYM, Pope TL, Jr., Ott DJ: Basic Radiology: http://www.accessmedicine.com/content.aspx?aID=2271105. • Mettler: Essentials of Radiology, 2nd ed. • P A Nee, J Benger and R M Walls. Airway management doi:10.1136/emj.2005.030635. Emerg. Med. J. 2008;25;98-102 • Physical examination of the spine By Todd J. Albert, Alexander R. Vaccaro • Steen, VD, Medsger, TA. Case-control study of corticosteroids and other drugs that either precipitate or protect from the development of scleroderma renal crisis. Arthritis Rheum 1998; 41:1613. • http://emedicine.medscape.com/article/238545-overview • http://education.yahoo.com/reference/gray/illustrations/figure;_ylt=AiXwKBJ25LQJ0A7brQ1WBY9tHokC?id=86 • http://www.ucl.ac.uk/news/news-articles/0709/07092002 • http://emedicine.medscape.com/article/331864-media • http://www0.sun.ac.za/ortho/webct-ortho/arthritis/aspirate-knee-s.jpg • https://www.bcbsri.com/BCBSRIWeb/images/mayo_popup/Scleroderma.jsp • http://emedicine.medscape.com/article/1265682-overview

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