Evaluation and management of rheumatologic emergencies in the ICU

Evaluation and management of rheumatologic emergencies in the ICU

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Evaluation and management of rheumatologic emergencies in the ICU DM Seminar: Dr.Vamsi Krishna Dept. of Pulmonary medicine
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Rheumatologic emergencies 19% of emergencies admitted to acute general medical wards have rheumatological problem as the cause for admission Spencer MA.Rheumatol Rehabil. 1981;20(2):71-3 Complications of rheumatic diseases frequently present with protean manifestations Slobodin G. Emerg Med J.2006;23(9):667-71
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Neurological emergencies
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Meningitis Acute onset illness; Fever, head ache, signs of meningeal irritation Neutrophilic pleocytosis Elevated protein Low glucose levels Gram stain and CSF culture + CSF Analysis Lymphocytic pleocytosis Normal/mild elevation of protein Normal sugar levels Gram stain and CSF culture - Aseptic meningitis Bacterial meningitis : Empirical antibiotics Ceftrioxone + Vancomycin + Ampicillin Active disease: SLE Behcet’s Vasculitides Treatment related: NSAIDS, IVIG induced Self limiting illness Steroids
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Stroke (CVA) Focal neurological deficit / TIA Neuroimaging S/O CVA CT/MRI brain ECHO, Carotid doppler aPL, LAC Vaso occlusion Bland infarct Vasculitic infarct : immunosuppression Libmansach’s endocarditis Carotid atherosclerosis Athero-embolic infarct Secondary to APLA Oral anticoagulation INR of 3 Steroids Anticoagulation Aspirin Risk factor reduction Control disease activity Therapeutic anticoagulation
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CNS vasculitis / diffuse vascular occlusion Head ache Altered sensorium Seizures Multiple neurological deficits MRI brain: Infarctions and bleeds Grey (cortex and deep)and white matter Angiography: Irregular narrowing, blunt ending and beading of small arterioles Brian / leptomeningeal biopsy + Vascular occlusion: APLA CNS vasculitis: SLE, PAN, Wegner’s Isolated CNS angitis Neither ruled out Therapeutic anticoagulation Methyl prednisolone + Cyclophosphamide Immunosuppression + anticoagulation Neuroimaging: Multiple infarcts (arterial + venous) LAC, aPL +
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Seizures In SLE and primary CNS angitis seizures are reported in upto 10% patients and in APLA, Wegner’s granulomatosis to a lesser extent (2-3%) Multiple etiologies: post CVA, uremia, meningitis, disease activity Treatment: Remove metabolic cause Seizures due to disease activity might respond to steroids alone Recurrent seizures respond to common antiepileptic drugs and long term treatment is not necessary Other causes of altered sensorium include malignant hypertension, TTP, steroid induced psychosis, uremic encephalopathy
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Hematologic emergencies
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TTP in SLE Typical features of CNS, renal dysfunction, thrombocytopenia, anemia, schistocytes in PBS Mimics disease flare sometimes Plasma exchange is treatment of choice Musio F. Semin Arthritis Rheum. 1998 ;28(1):1-19 Plasma exchange daily sessions to be given till platelet count is >50,000/cc for 2 consecutive days Poor response to immunosuppressants when used alone steroids and CYC used as adjunctive therapy Relapses are common Scleroderma crisis and catastrophic APLA mimic TTP
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Hematological emergencies Syndrome
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This note was uploaded on 12/03/2011 for the course MEDICINE 350 taught by Professor Dr.aslam during the Winter '07 term at Medical College.

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Evaluation and management of rheumatologic emergencies in the ICU

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