Rosen & Barkin's 5-Minute Emergency Medicine Consult (59 page)

• Pelvic radiograph: Should be done in any adult patient suspected of undiagnosed ankylosing spondylitis:
  
  • Sacroiliitis is essential to the diagnosis of AS; this is seen initially as subchondral bony erosions on the iliac side of the SI joint, which later manifest as bony proliferation and sclerosis.
    
  • If plain films are negative for sacroilitis, MRI should be considered.
    
• Lumbar, thoracic, and cervical spine radiographs to exclude fracture for complaint of new pain to these areas with or without trauma
  
• CT should be performed to further evaluate possible fractures on plain radiographs.
  
• MRI should be performed emergently on any patient with neurologic deficit.
  
• Chest radiograph may show patchy inflammatory infiltrates or apical fibrosis.
  

• Electrocardiogram indications:
  
  • Symptoms of acute coronary syndrome (slightly increased risk compared to general population for CAD)
    
  • Symptomatic arrhythmia:
    
    • AV block
      
• Echocardiogram indications:
  
  • New murmur: Increased predilection for aortic insufficiency with AS
    
  • Evidence of new heart failure.
    

• JAS:
  
  • Onset before age 20
    
  • More enthesitis and extraspinal joint involvement.
    
• Reactive arthritis (formerly Reiter syndrome):
  
  • Arthritis, urethritis, and conjunctivitis beginning about 1 mo after an episode of urethritis or enteritis.
    
• Enteropathic arthritis:
  
  • Crohn's disease or ulcerative colitis
    
  • Primarily involves knee, elbow, ankle, or wrist, and usually exacerbated by flares of the bowel disease
    
• Psoriatic arthritis:
  
  • Psoriasis rash
    
  • Much greater predilection for the hands and feet with higher incidence of dactylitis.
    
• Septic arthritis:
  
  • Exclude with arthrocentesis if clinically suspected in single joint involvement.
    
• Mechanical low back pain:
  
  • Improved with rest and exacerbated by exercise without signs of systemic inflammatory process.
    
• Spinal epidural abscess:
  
  • More constant, unremitting, and typically associated with fever and history of IVDA or immunosuppression.
    
• Neoplastic low back pain:
  
  • Typically in patients older than 40, more constant and unremitting, and more characteristically at night.
    

TREATMENT

• Exclude cord compression if clinically suspected (MRI is the study of choice).
  
• Exclude spinal fracture for any new spinal pain (CT may be necessary).
  
• Exclude infection if clinically suspected with laboratory analysis and arthrocentesis.
  
• Control pain and inflammation with NSAIDs
  

• Nonselective NSAIDs:
  
  • Ibuprofen: 35 mg/kg/d divided QID, max. 50 mg/kg/d (adult: 300–800 mg PO TID or QID)
    
  • Indomethacin: 1–2 mg/kg/d divided BID or QID, max. 4 mg/kg/d (adult: 25 mg PO BID or TID)
    
    • Not well tolerated, especially at higher doses because of GI and CNS effects
      
  • Naproxen: 10 mg/kg/d divided BID, max. 1,000 mg/d (adult: 250–500 mg PO BID)
    
• COX 2 inhibitors:
  
  • Celecoxib (adult: 100 mg–200 mg PO BID)
    
• TNF-α inhibitors:
  
  • Adalimumab (adult: 40mg SubQ q2wk)
    
  • Etanercept (adult: 50mg SubQ qwk)
    

• NSAIDs should be avoided in pregnancy.
  
  • Acetaminophen is 1st line
    
  • Opioids are 2nd line
    

NSAID use may increase risk in the elderly for cardiovascular disease, GI bleeding, renal function, and hypertension. Although effective in select patients, close follow-up is prudent.

Consider if NSAIDs or acetaminophen are ineffective at appropriate doses:

• Opioid analgesics, muscle relaxants, or low-dose steroids.
  

FOLLOW-UP

• Acute neurologic impairment
  
• Intractable pain
  
• Sepsis or septic joint cannot be excluded.
  

• No serious injuries or neurologic deficit
  
• Pain is manageable to the patient
  

• The patient should be encouraged to obtain a medical alert bracelet.
  
• Rheumatology:
  
  • Patients with evidence of a new diagnosis of AS should be considered for early referral to a specialist in rheumatology for immunomodulative therapy.
    
• Physical medicine and rehabilitation:
  
  • Resting splints for inflamed joints
    
  • Orthoses for enthesitis (such as heel cushion inserts to rest Achilles tendon attachment)
    

• Routine primary care re-evaluation within 1–2 wk to assess response to treatment.
  
• Referral to a rheumatologist for immunomodulating medications.
  
• Earlier follow-up in any patient with higher risk for adverse response to NSAIDs:
  
  • Elderly, hypertensive patients, and patients with higher GI bleeding risks.
    

• Intubation is likely to be difficult and should avoid neck repositioning due to risk of C1 subluxation.
  
  • Consider airway adjuncts (such as LMA) until a definitive airway (usually fiberoptic) can be safely assured.
    
• Immobilization must avoid creating additional injury
  
  • Consider cushion/tape stabilization in position of comfort rather than standard cervical collar and backboard
    
• Minor traumatic injuries in AS can result in spinal fracture and possible cord injury. Maintain a high clinical suspicion.
  

• Baraliakos X, van den Berg R, Braun J, et al. Update of the literature review on treatment with biologics as a basis for the first update of the ASAS/EULAR management recommendations of ankylosing spondylitis.
  Rheumatology.
  2012;51(8):1378–1387.
  
• Chakravarty SD, Paget SA. Ankylosing spondylitis: Pathogenesis, diagnosis, and therapy.
  Rheumatology.
  2012;40:39--43.
  
• Sieper J, Braun J.
  Ankylosing Spondylitis: In Clinical Practice
  . Britain: Springer, 2010.
  

See Also (Topic, Algorithm, Electronic Media Element)

http://www.spondylitis.org

CODES

720.0 Ankylosing spondylitis

BASICS

• Central and peripheral cholinergic blockade
  
• Depending on the drug involved, antagonism occurs at muscarinic (most common), nicotinic, or both receptors.
  
• Onset of activity: 15–30 min after ingestion
  
• Duration of effect: 2–24 hr