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Ponte Vedra ED Arthritis 2013

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by Nicholas Genes on 19 June 2013

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Transcript of Ponte Vedra ED Arthritis 2013

Nicholas Genes, MD, PhD, FACEP
Icahn School of Medicine at Mount Sinai
Department of Emergency Medicine
June 21, 2013
hot news for hot joints:
updates in the diagnosis and
management of
arthritis in the ED
disclosures:
Medscape Emergency Medicine
Emergency Physicians Monthly
Emergency Medicine Practice
new thresholds for treating septic arthritis

management of acute gout pain

pain relief for arthritis flare
accordingly, today's focus:
"acute" arthritis
monoarticular arthritis
septic arthritis (non GC)
Lyme arthritis
reactive arthritis
polyarticular arthritis
gonococcal arthritis
gout
pseudogout
I used to work with rheumatologists
likelihood of septic arthritis
age 80+ ? [LR+ 3.5]
recent surgery? [LR+ 6.9 to 15]
other hx elements? not well studied
fever? [LR+ 0.67]
other findings not well studied
[LR+ 1.4-1.7]
[LR- 0.28-0.84]
[LR+ 1.3-7.0]
[LR- 0.17-2.4]
[LR+ 1.3-7.0]
[LR- 0.3-0.7]
interpreting arthrocentesis data
sWBC
sLactate

gram stain / culture
crystals
viscosity
sLDH and other substances
PMN > 90% gives [LR+ 2.7] and [LR- 0.51]
three studies (two were probably L-lactate)

synovial lactate > 10 mmol/L = high [LR+] low [LR-]
synovial lactate < 5.5 mmol / L = [LR+ 0 to 0.05]



all were send-out tests
point-of-care GEM or iSTAT ?
50 - 80% sensitive (or 29-65%)

use bottles for culture, not tubes

sLDH < 250 U / L may rule out (one trial)

TNF, procalcitonin, PCR all show promise

synovial glucose is worthless

NSAIDs vs. colchicine for acute gout
both considered first-line

no head-to-head trials

no apparent difference between ibuprofen, indomethacin , naproxen



Terkeltaub et al RCT:
colchicine 1.2mg then 0.6mg one hour later vs.
colchicine 4.8mg over 6 hours

Low-dose regimen = fewer GI events,
comparable relief

FDA exclusivity led to “Colchrys”
was $0.09 / pill, now $4.85 / pill

gout and IA or systemic steroids

no placebo-controlled trial of IA steroids

one uncontrolled trial of IA triamcinolone (in NSAID-intolerate pts) showed relief w/in 48h

systemic steroids = more side effects, but advantages for polyarticular gout

IA steroids take ~ 24 hours to relieve pain

amide anesthetics like lidocaine are
safe & effective in many uses, including orthopedics

post-op trials show early ambulation,
reduced LOS, opioid use

devastating cartilage degeneration following
post-op continuous-infusion lidocaine pumps

in vitro and rat models suggest one injection
leads to histologic changes within weeks

local anesthetic injections falling out of favor

topical NSAIDs offer less adverse events
topical diclofenac q6h comparable to oral, >placebo

capsaicin in RA shows benefit (Cochrane review)
primary side effect?

cannabinoids
15/18 trials showed significant analgesia in RA,
fibromyalgia flares (no adverse events, better sleep)
Can’t rule out septic arthritis without tap
sWBC > 50k often enough to cross tx threshold
sLactate promising, sLDH < 250 U/L may rule out

for acute gout:
colchicine 1.2mg up front, 0.6mg 60 min later
NSAIDs just as effective, now much cheaper

skip the IA lidocaine, consider topical NSAIDs
(even less for GC arthritis)
acute flares of
chronic arthritis
EM approach to arthritis:
is that a septic joint?
if not, maybe I can make them more comfortable
history
exam
X-rays
serum tests:
WBC
ESR, CRP
other arthrocentesis tests:
in summary...
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