Wednesday Wrap Up 11/12/14

Welcome to our weekly Wednesday Wrap Up from conference today.

Dr. Rebecca Carter

Acute monoarthritis is septic until proven otherwise
The most common pathogen is?
Staph aureus, but consider others in unusual presentations (IVDU, immunosuppression, underlying joint disease or prosthetic joints)
Imaging and labs aren’t very helpful in diagnosing septic arthritis, but are good for excluding other causes of joint pain
Start empiric abx early based on patient profile and smear, tailor for definitive therapy

References:

Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. Ch 281. Acute Disorders of the Joints and Bursae

EM Practice: Arthritis in the ED. October 2004

http://emedicine.medscape.com/article/236299-overview

Dr. Michael Griesinger

1. Pre-LP CT: the majority of patients do not require CT scan before LP, BUT guidelines recommend CT scan for?

Immunocompromised, history of CNS disease, seizures, papilledema, AMS, or focal neuro deficit.

2. Don’t delay treatment in toxic-appearing patients.

3.Empiric treatment in adults > 50 are?

Vancomycin, Ceftriaxone, and Ampicillin to cover for pen-resistant Strep pneumo, N. meningitidis, and Listeria, respectively.

4. Give dexamethasone in suspected cases of Strep pneumo (or H. flu in pediatrics) before or concurrently with first dose of abx to prevent long-term neuro sequelae.

5. There is a disease entity practically unique to NYC called rickettsialpox associated with mice infestations – treat it, like other rickettsial infections, with doxycycline.

Dr. Jacqueline Shibata

1. If you have a painful joint with limited movement, think about your clinical picture, but then, Tap It.

2. Sensitive tests: ESR >30, synovial LDH > 250, +Crystals

3. Specific tests: Positive gram stain, synovial WBC >50,000, sLactate >10

4. Tap it!

5. Why? Because septic joints have high morbidity and mortality.

6. Treatment and Dispo?

Give Vancomycin and Ceftriaxone and admit to Ortho.

Dr. Shibata's References

Recommended: Mallin et al. Hip Ultrasound, Aspiration and Injection. Emergency Ultrasound Podcast. Episode 28. 2012.

Recommended: Carpenter CR, et al. Evidence-based Diagnostics: Adult Septic Arthritis. Acad Emerg Med. 2011. Aug;18(8):781-.‐96.

Rios C, Zehtabchi S. Emergency Department Patient With Joint Pain: Searching for the Optimal Diagnosis Tool. Ann Emerg Med. 2008; 52:567-569. Septic Arthritis in the

Lenski et al. Analysis of synovial inflammatory markers to differ infectious from gouty arthritis. Clinical Biochemistry. 2014 Jan: Vol 47. Issue 1-2: 49-55.

Burton JH. Chapter 281. Acute Disorders of the Joints and Bursae. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011.

Schmerling et al. Synovial fluid tests: what should be ordered? JAMA. 1990; 264:1009-

Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann. Emerg. Med. 2010;55(3):284-9.

Tsung JW, Blaivas M. Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound. J. Emerg. Med. 2008;35(4):393-9.

By Dr Andrew Grock, Dr. Carl Alsup, and Dr. Jay Khadpe