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

CCFP MedleyCCFP Medley

Rheumatological EmergenciesVavular HD & Endocarditis

Spinal #’s

Rheumatological EmergenciesVavular HD & Endocarditis

Spinal #’s

Rheumatology in the EdRheumatology in the Ed

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

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

Acute Painful JointAcute 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

• 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

Septic arthritisSeptic arthritis

• Acute monoarthritis is septic until proven otherwise

• Acute monoarthritis is septic until proven otherwise

Who is at risk for SA?Who is at risk for SA?

• immunocompromised• RA and other inflammatory

arthritis (including gout)• Prosthetic joints• IVDU

• immunocompromised• RA and other inflammatory

arthritis (including gout)• Prosthetic joints• IVDU

Clinical FeaturesClinical Features

• Knee > hip > shoulder > wrist > ankle > elbow

• 20% afebrile on presentation

• Pain is remarkable and limitation of ROM significant unless prior Abx

• Knee > hip > shoulder > wrist > ankle > elbow

• 20% afebrile on presentation

• Pain is remarkable and limitation of ROM significant unless prior Abx

Diagnostic TestingDiagnostic 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

• 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

Arthrocentesis in SAArthrocentesis 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

• 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

Pitfalls in Synovial Fluid Interpretation

Pitfalls in Synovial Fluid Interpretation

• Early• Previous antibiotics• Immunosuppressed

• Synovial WBC’s 2000-5000 not uncommon

• Early• Previous antibiotics• Immunosuppressed

• Synovial WBC’s 2000-5000 not uncommon

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

Septic BursitisSeptic 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

• 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

SLE in the EDSLE in the ED


• Fever– Immunocompromised

• Neuro– Seizures– CVA– Psychosis

• Lupus cerebritis

• CT head, LP R/O meningoencephalitis– Bacterial, fungal, TB, brain abscess all possible

• Fever– Immunocompromised

• Neuro– Seizures– CVA– Psychosis

• Lupus cerebritis

• CT head, LP R/O meningoencephalitis– Bacterial, fungal, TB, brain abscess all possible

SLE in the EDSLE in the ED• Cardiac

– Pericarditis• Effusions usually benign

– Myocarditis• Common, usually little clinical

manifestation

– CAD• Increased prevalence

• Cardiac– Pericarditis

• Effusions usually benign

– Myocarditis• Common, usually little clinical

manifestation

– CAD• Increased prevalence


• Pulmonary– Pleural effusions– PE – Oppurtunistic infections– Lupus pneumonitis (Dx of exclusion)

• Chest pain/dyspnea in the SLE patient very serious complaint

• Pulmonary– Pleural effusions– PE – Oppurtunistic infections– Lupus pneumonitis (Dx of exclusion)

• Chest pain/dyspnea in the SLE patient very serious complaint


• NSAIDS may worsen lupus nephritis

• NSAIDS may worsen lupus nephritis

RA in the EDRA in the ED• Fever

– Immunosuppressed

• Acute joint– Do not dismiss monoarthritis as RA

flare • Think septic joint first• They know their disease

• Fever– Immunosuppressed

• Acute joint– Do not dismiss monoarthritis as RA

flare • Think septic joint first• They know their disease

RA in the EDRA 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

• 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

RA in the EDRA in the ED

• Trauma– Neck pain & neuro signs

• Rupture of transverse ligament, displacement of odontoid

• Trauma– Neck pain & neuro signs

• Rupture of transverse ligament, displacement of odontoid



Blood Culture ResultBlood Culture Result

• July 1st• Abnormal lab result

– Single BC + coag negative staph?

– Single BC + Staph aureus?

• July 1st• Abnormal lab result

– Single BC + coag negative staph?

– Single BC + Staph aureus?

Infective Endocarditis (IE)Infective Endocarditis (IE)

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

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

Clinical FeaturesClinical 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

• 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

IE: Clinical SuspicionIE: Clinical Suspicion



IE: Clnical SuspicionIE: Clnical Suspicion









IE: Diagnostic Work-upIE: 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

• 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

IE: Diagnostic CriteriaIE: Diagnostic Criteria

• Duke Criteria– 2 major or 1 major/3 minor or 5 minorMajor

BC + from at least 2ECHO evidence

MinorPredispositionFeverStigmata (cutaneous, conunctival etc.)Single + BCECHO abnormal not meeting criteria

• Duke Criteria– 2 major or 1 major/3 minor or 5 minorMajor

BC + from at least 2ECHO evidence

MinorPredispositionFeverStigmata (cutaneous, conunctival etc.)Single + BCECHO abnormal not meeting criteria

IE: ManagementIE: Management

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

• Vanco + Gent• Ceftriaxone + Gent

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

• Vanco + Gent• Ceftriaxone + Gent

Quick CaseQuick Case

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

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

Acute Valvular RuptureAcute 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

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

Severe ASSevere AS

• CHF + exertional syncope• Tenuous pre/afterload balance• 1cm/50mmHg• Medication change?

• Gentle fluid resus if hypotensive

• Cardiology admission– Assess if surgical candidate

• CHF + exertional syncope• Tenuous pre/afterload balance• 1cm/50mmHg• Medication change?

• Gentle fluid resus if hypotensive

• Cardiology admission– Assess if surgical candidate

Quick CaseQuick Case

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

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

Prosthetic ValveProsthetic Valve

• Type, location, age• Ask for surgical card• Almost all some degree of

narrowing– mild systolic murmur common

• Diastolic murmur always abnormal– failure

• Type, location, age• Ask for surgical card• Almost all some degree of

narrowing– mild systolic murmur common

• Diastolic murmur always abnormal– failure

Acute Valvular FailureAcute 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

• 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

Valvular EmergenciesValvular Emergencies

• IE• Rupture of native valve• Critical AS• Acute failure of prosthetic valve

– Thrombosis– Mechanical breakdown

• Embolization– Debris, clot, actual valve structure

• Hemolysis

• IE• Rupture of native valve• Critical AS• Acute failure of prosthetic valve

– Thrombosis– Mechanical breakdown

• Embolization– Debris, clot, actual valve structure

• Hemolysis























Thoracic #’sThoracic #’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

• 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





Lumbar Spine #’sLumbar Spine #’s

• Very common• Wedge compression

– Loss of 25-30% ant height necessitates CT scan

• Compression burst– Retropulsion common– Always CT

• Very common• Wedge compression

– Loss of 25-30% ant height necessitates CT scan

• Compression burst– Retropulsion common– Always CT



SummarySummary• 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

• 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

Documents

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