Rosen & Barkin's 5-Minute Emergency Medicine Consult (120 page)

• Nonseptic bursitis:
  
  • Rest and removal of aggravating factors (e.g., avoid direct pressure and repetitive use; protective padding where necessary)
    
  • Ice affected areas for 10 min, 4 times a day until improved; may alternate with heat.
    
  • NSAIDs for at least 7 days; best if continued for 5 days after improvement to help prevent recurrence
    
  • If fluctuant, then aspirate and place compression dressing
    
  • If no improvement within 5–7 days and infection has been ruled out (by culture), injection of lidocaine and corticosteroids may be considered:
    
    • Mix 2 mL of 2% lidocaine with appropriate depo-corticosteroid (see below) and inject 1–3 mL of this mixture into the bursa using sterile technique.
      
    • Steroid injections should not be repeated until 4 wk have passed, and no >2 injections per bursa should be performed without consultation.
      
• Septic bursitis:
  
  • Superficial bursae: Aspiration and antibiotics may be sufficient with close follow-up.
    
  • Other major bursae: Antibiotics and drainage of bursae (leaving in perforated drainage catheter can reduce period of treatment and avoid eventual bursectomy)
    
  • Febrile patients may need IV antibiotics.
    
  • Base antibiotic choice on the Gram stain when available or empiric coverage based on local susceptibilities:
    
    • Penicillinase-resistant penicillins may be used if Gram stain shows gram-positive cocci in chains but should be broadened for MRSA coverage if cocci in clusters are seen
      
    • If gram-negative organisms are found, blood cultures should be done and another primary source for the infection should be sought.
      
• Antibiotics should be continued for 5–7 days beyond resolution of signs of infection (thus may require follow-up)
  
• Treat associated diseases as needed (e.g., gout).
  

• NSAIDs (many choices; a few are listed here):
  
  • Naprosyn: 500 mg PO q12h
    
  • Ibuprofen: 600 mg PO q6h (peds: 5–10 mg/kg PO q6h)
    
  • Ketorolac: 30 mg IV/IM q6h or 10 mg PO q4h–q6h
    
  • Meloxicam: 7.5 mg PO q12h or 15 mg PO daily
    
• Corticosteroids for intrabursal injection:
  
  • Triamcinolone acetonide: 20–40 mg (1st choice)
    
  • Methylprednisolone acetate: 20–40 mg
    
  • Dexamethasone acetate/sodium: 8 mg
    

FOLLOW-UP

• Most patients may be treated as outpatients.
  
• Most patients respond to therapy in 3–4 days and may follow-up within 1 wk or PRN.
  
• Septic bursitis requires repeated bursal aspiration every 3–5 days until sterile.
  

• Patients with systemic inflammatory response syndrome (SIRS), large surrounding cellulitis, unable to take PO antibiotics, failed outpatient therapy, or immunosuppressed
  
• Unusual organisms, extrabursal primary site, or deep bursal involvement
  

• Able to tolerate pain
  
• Septic bursitis are safe to discharge if appropriately treated and close follow-up is secure
  

Rheumatology or orthopedic referral is recommended for patients who do not respond to intrabursal steroids or recurrent bursitis or need operative management.

• Close follow-up for septic bursitis
  
• PRN to the emergency department for worsening symptoms but otherwise follow-up with primary care physician.
  

• Exam alone may be unreliable in distinguishing between traumatic and septic bursitis:
  
  • Aspiration and fluid analysis may be the only method of distinguishing.
    
• Beware of risk for GI hemorrhage associated with PO NSAIDs and for nephrotoxicity with ketorolac
  
• If presents with the 4 signs of infection—
  humor, dolor, rubor,
  and
  calor
  —then it is likely septic but still needs an aspiration and culture
  
• Beware of the potential of seeding organisms to adjacent joints when aspirating septic bursae.
  

• DeLee JC, Drez D, Miller MD, ed.
  DeLee & Drez’s Orthopaedic Sports Medicine: Principles and Practice
  . 3rd ed. Philadelphia, PA: Saunders Elsevier; 2010:889–891, 1209–1212, 1246–1249, 1455–1458, 2030–2041.
  
• Fayad LM, Carrino JA, Fishman EK. Musculoskeletal infection: Role of CT in the emergency department.
  Radiographics
  . 2007;27(6):1723–1736.
  
• Larsson L, Baum J. The syndromes of bursitis.
  Bull Rheum Dis
  . 1986;36(1):1–8.
  
• Stephens MB, Beutler Al, O’Connor FG. Musculoskeletal injections: A review of the evidence.
  Am Fam Physician
  . 2008;78(8):971–976.
  
• Baumbach SF, Wyen H, Perez C, et al. Evaluation of current treatment regimens for prepatellar and olecranon bursitis in Switzerland.
  Europ J Trauma Emerg Surg.
  2013;39(1):65–72.
  

CODES

• 726.10 Disorders of bursae and tendons in shoulder region, unspecified
  
• 726.33 Olecranon bursitis
  
• 727.3 Other bursitis
  

BASICS

• 3 classes of calcium channel blockers (CCBs):
  
  • Phenylalkylamines (verapamil):
    
    • Vasodilation resulting in a decrease in BP
      
    • Negative chronotropic and inotropic effects: Reflex tachycardia not seen with a drop in BP.
      
  • Dihydropyridine (nifedipine):
    
    • Decreased vascular resistance resulting in a drop in BP
      
    • Little negative inotropic effect: Reflex tachycardia occurs
      
  • Benzothiazepine (diltiazem):
    
    • Decreased peripheral vascular resistance leading to a decrease in BP
      
    • Heart rate (HR) and cardiac output initially increased
      
    • Direct negative chronotropic effect, which leads to a fall in HR
      
• Effects of calcium channel blockade
  
  • Calcium plays key role in cardiac and smooth muscle contractility
    
  • CCBs prevent
    
    • the entry of calcium, resulting in a lack of muscle contraction
      
    • the normal release of insulin from pancreatic islet cells, resulting in hyperglycemia
      

DIAGNOSIS

• Cardiovascular:
  
  • Hypotension
    
  • Bradycardia
    
  • Reflex tachycardia (dihydropyridine)
    
  • Conduction abnormalities/heart blocks
    
• Neurologic:
  
  • CNS depression
    
  • Coma
    
  • Seizures
    
  • Agitation
    
  • Confusion
    
• Metabolic:
  
  • Hyperglycemia
    

• Inquire about risk of medication error.
  
• Inquire about risk of suicidal ideation with intent.
  
• Inquire about possible exposure to medications with a pediatric patient.
  

• Hypotension
  
• Bradycardia
  
• Skin may be warm instead of cool and clammy.
  

ECG:

• Bradycardia (reflex tachycardia with nifedipine)
  
• Conduction delays: QRS complex prolongation
  
• Heart blocks
  

• Ionized calcium level when administering calcium
  
• Digoxin level if patient taking digoxin (dictate safety of calcium administration)
  
• CBC
  
• Electrolytes, BUN, creatinine, glucose
  
  • Strongly consider CCB overdose in the setting of bradycardia, hypotension, and hyperglycemia
    
  • Degree of hyperglycemia may correlate with severity of CCB poisoning in nondiabetics
    
• Toxicology screen if coingestants suspected
  

• β-Blocker toxicity
  
• Clonidine toxicity
  
• Digitalis toxicity
  
• Acute myocardial infarction with heart block
  

TREATMENT