rheumatolgic emergencies. conflicts none errors - mine. thanks to: dr. walker dr. hadley dr. del...
Post on 13-Jan-2016
223 Views
Preview:
TRANSCRIPT
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
Non-Inflammatory Trauma HbS Osteonecrosis
Inflammatory Crystals Bacteria Rheumatiod Arthritis Spondyloarthropathy SLE Sarcoidosis Bursitis
Acute Monoarthritis
Septic joint in RA – overlooked Delay of Dx 1-3 weeks Significant joint damage Mortality 20 - 33%
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
Red and Hot
'The most important laboratory test in evaluating monarticular joint pain is synovial fluid analysis.' UTDOL.
WBC not enough
Normal Noninflammatory Inflammatory Septic
WBC/mm3 <200 200 -2,000 2,000-100,000 15,000->100,000
PMN% <25 <25 >50 >75
Colour Clear Yellow Yellow to opalescent Yellow to purulent
Gl mg/dL .=serum .=serum May be low Very low
What to order
Look at it Xantho, clear, cloudy, purulent
Total leukocyte count and diff Gram stain and culture Crystals (polarizing micro) Glucose
WBC not enough
Normal Noninflammatory Inflammatory Septic
WBC/mm3 <200 200 -2,000 2,000-100,000 15,000->100,000
PMN% <25 <25 >50 >75
Colour Clear Yellow Yellow to opalescent Yellow to purulent
Gl mg/dL .=serum .=serum May be low Very low
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
http://www.medscape.com/viewarticle/706761
http://www.medscape.com/viewarticle/706761
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
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.
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)
C5-C6
Inverted radial reflex
Predicted Problems
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.
Sceroderma
Sceroderma
Scleroderma Renal Crisis
~10-20% develop it. ~20% mortality. ~20% will need HD after crisis.
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
Scleroderma Renal Crisis
Steroids?
Scleroderma Renal Crisis
What to do? ACEi (Grade 1A). Captopril (Grade 2B) – no CNS s/s.
Add Nitroprusside – WITH CNS s/s. Nephro.
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
Lit review up to 2004 23 studies, 2036 pts, 5 languages. May be helpful, caution with test results.
The future
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
Giant Cell Arteritis- Aortitis
GCA – 27% pt large artery complications. Ascending aortic aneurysms 17x AAA 2.5x Suspect it
Hx, RF CT / MRI
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%
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
Atlantoaxial subluxation
Anterior atlantodens interval
McRae's Line McGregor's Line
Atlantoaxial subluxation
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?
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.
Adrenal Insufficiency
Tx NS Glc Hydrocortisone 100 mg IV Or: (dexamethasone 4 mg IV – no impact on ACTH
test or cortisol level)
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
top related