CCFP Medley

1. CCFP Medley Rheumatological Emergencies Vavular HD & Endocarditis Spinal #’s

2. Rheumatology in the Ed • Acute Joint • Septic arthritis • Septic bursitis • SLE in the ED • RA in the ED

3. 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

4. Septic arthritis • Acute monoarthritis is septic until proven otherwise

5. Who is at risk for SA? • immunocompromised • RA and other inflammatory arthritis (including gout) • Prosthetic joints • IVDU

6. Clinical Features • Knee > hip > shoulder > wrist > ankle > elbow • 20% afebrile on presentation • Pain is remarkable and limitation of ROM significant unless prior Abx

7. 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 • Aren’t back in the ED • Only 50% positive

8. Arthrocentesis in SA • Arthrocentesis essential • Thin, turbid • Cell count 5000 - > 50000 • Only 50-70% > 50000 • >75% PMNs • Glucose < 50% serum • GS positive in 50-70% • If unclear, ortho opinion, admit, cover with Abx until BC return

9. Pitfalls in Synovial Fluid Interpretation • Early • Previous antibiotics • Immunosuppressed • Synovial WBC’s 2000-5000 not uncommon

11. Septic Bursitis • Olecranon and prepatellar common • Difficult distinction • When septic usually peribursal swelling and erythema +/- cellulitis • No standardized approach • Aspiration if concerned • WBC > 5000 likely septic • Septic? I&D, IV Abx, F/U HPTP • Indeterminate? Oral Abx, F/U

12. SLE in the ED

13. 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

14. SLE in the ED • Cardiac • Pericarditis • Effusions usually benign • Myocarditis • Common, usually little clinical manifestation • CAD • Increased prevalence

15. 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

16. SLE in the ED • NSAIDS may worsen lupus nephritis

17. RA in the ED • Fever • Immunosuppressed • Acute joint • Do not dismiss monoarthritis as RA flare • Think septic joint first • They know their disease

18. RA in the ED • Cardiac • Increased predisposition to CAD • Unclear • chronic inflammation, steroids accelerating atherosclerosis, vasculitis • Pericarditis/pericardial effusions in @40% of patients • Neuro • Nerve entrapment and neuritis common

19. RA in the ED • Trauma • Neck pain & neuro signs • Rupture of transverse ligament, displacement of odontoid

21. Blood Culture Result • July 1st • Abnormal lab result • Single BC + coag negative staph? • Single BC + Staph aureus?

22. Infective Endocarditis (IE) • Prosthetic HV • IVDU • PHx endocarditis • Rheumatic or CHD • Calcific degenerative valve dz • MVP

23. 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

24. IE: Clinical Suspicion

25. IE: Clnical Suspicion

26. IE: Clnical Suspicion

27. IE: Clnical Suspicion

28. IE: Diagnostic Work-up • Lab findings nonspecific • Leukocytosis <50% • 3 sets of BC’s • 1st and last 1 hour apart • 90-95% positive unless prior Abx • TEE vs TTE

29. 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

30. IE: Management • Febrile prosthetic valve patients or persistent fever in IVDU - err on admission • Vanco + Gent • Ceftriaxone + Gent

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

32. 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

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

34. Quick Case • 70f, AoVR, near-synopal at home • Hypotensive, CHF

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

36. 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

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

48. 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