Rosen & Barkin's 5-Minute Emergency Medicine Consult (622 page)

• Careful exam to look for skin lesions/joint swelling
  
• Careful heart and lung exam
  
• Throat swab for rapid strep test or culture
  
• ECG
  
• Chest x-ray
  
• Echocardiogram
  
• See other labs below
  

• Rapid antigen strep test
  
• Throat culture
  
• ASO titer
  
• CBC
  
• ESR or C-reactive protein
  
• Other serology tests to rule out other rheumatologic diseases
  

• Chest radiograph
  
• Echocardiogram
  

• ECG
  
• Diagnosis is based on clinical picture and meeting Jones criteria
  

• Juvenile idiopathic arthritis
  
• Infective endocarditis
  
• Reiter syndrome
  
• Systemic lupus erythematosus
  
• Postgonococcal arthritis
  
• Other infectious causes of arthritis and carditis:
  
  • Coxsackie B virus and parvovirus
    

Rheumatic fever is primarily a pediatric disease but can occur in young adults. Testing for strep throat is not recommended under 3 yr of age in US due to low incidence of strep throat and rare ARF

Prenatal counseling recommended if woman has a history of rheumatic fever due to increased cardiac risks

TREATMENT

• Oxygen as needed
  
• Monitors if in distress
  
• IV access may be prudent
  

Some patients in CHF will need airway management

• Pericardial effusions may need drainage
  
• In severe carditis, start prednisone
  
• In case of severe chorea, start haloperidol
  
• Penicillin IM, IV, or PO
  
• Aspirin for arthritis/arthralgia
  

• Aspirin: 4–8 g/d (peds: 100 mg/kg/d) PO q4–6h; do not exceed 4 g/24h
  
• Azithromycin 500 mg day 1, then 250 mg PO for 4 more days. (peds: 10 mg/kg day 1 then 5 mg/kg daily PO for 4 more days)
  
• Digoxin: 0.25–0.5 mg (peds: 0.04 mg/kg) IV
  
• Erythromycin: 250 mg (peds: 30–50 mg/kg/d) q6h PO for 10 days
  
• Furosemide: 20–80 mg (peds: 1 mg/kg/dose) IV
  
• Haloperidol: 2–10 mg (peds: 0.01–0.03 mg/kg/d; use only >2 yr and >15 kg) q6h IM or PO
  
• Penicillin (benzathine benzylpenicillin): 1.2 million U (peds: 600,000 U for <27 kg) IM acutely and monthly thereafter (prophylaxis)
  
• Penicillin VK: 500 mg (peds: 250 mg) PO q8h for 10 days (acute treatment)
  
• Prednisone: 1–2 mg/kg/d for 14 days with taper for the next 2 wk
  

• Aspirin (carditis patients)
  
• Penicillin
  
• Haloperidol (for chorea)
  

Corticosteroids

FOLLOW-UP

Most patients with a new diagnosis should be admitted for stabilization and further evaluation of the severity of the heart disease.

• CHF
  
• New diagnosis
  
• Uncontrolled chorea
  
• Uncontrolled pain
  
• Pericardial effusion
  

• Pain is controlled
  
• Stable cardiovascular status
  
• Education regarding prolonged treatment and endocarditis prophylaxis
  
• Patient has reliable follow-up option
  

• All patients need close follow-up with their primary physician and cardiologist
  
• Consider referral to infectious disease specialist and rheumatologist
  

• Cardiology for echocardiogram and advice on subacute bacterial endocarditis prophylaxis
  
• Infectious disease specialist to advise on prolonged use of penicillin to prevent recurrence
  
• Rheumatology if needed for chronic joint problems (uncommon)
  

• Rheumatic fever is uncommon in US, but must be vigilant to treat strep infections to prevent resurgence of disease
  
• More common in patients living in poor and crowded conditions
  
• No need to do throat cultures in children under age 3
  

• American Academy of Pediatrics. Group A Streptococcal infections. In: Pickering LK, Baker CJ, Kimberlin DW, et al.,eds.
  Red Book 2012 Report of the Committee of Infectious Diseases
  . 668–680.
  
• Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever.
  Lancet.
  2005;366:155–168.
  
• Chang, C. Cutting edge issues in rheumatic fever.
  Clin Rev Allergy Immunol.
  2012;42:213–237.
  
• Cilliers AM. Rheumatic fever and its management.
  BMJ
  . 2006;333:1153–1156.
  
• Gerber MA, Baltimore RS, Eaton CB, et al. Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: A scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: Endorsed by the American Academy of Pediatrics.
  Circulation
  . 2009;119:1541–1551.
  
• Miyake CY, Gauvreau K, Tani LY, et al. Characteristics of children discharged from hospitals in the United States in 2000 with the diagnosis of acute rheumatic fever.
  Pediatrics
  . 2007;120:503–508.
  
• Weiner SG, Normandin PA. Sydenham chorea: A case report and review of the literature.
  Pediatr Emerg Care
  . 2007;23:20–24.
  

See Also (Topic, Algorithm, Electronic Media Element)

Pharyngitis

CODES

• 390 Rheumatic fever without mention of heart involvement
  
• 391.9 Acute rheumatic heart disease, unspecified
  
• 714.0 Rheumatoid arthritis
  

BASICS

• Result of major or minor thoracic trauma
  
• Can be classified as traumatic or pathologic
  

• Blunt thoracic trauma:
  
  • Simple fall, fall from height
    
  • Motor vehicle crash
    
  • Assault
    
  • Missile
    
  • CPR-related
    
• Penetrating trauma is a less likely cause.
  
  • Ribs usually break at the point of impact or the posterior angle, the structurally weakest region
    
• Stress fractures in upper and middle ribs can occur with recurrent, high force movements:
  
  • Athletic activities: Golf, rowing, throwing
    
  • Severe cough
    
• Pathologic fractures associated with minor trauma or significant underlying disease:
  
  • Advanced age
    
  • Osteoporosis
    
  • Neoplasm
    

• Relatively elastic chest wall makes rib fractures less common in children.
  
• Consider nonaccidental trauma for infants and toddlers without appropriate mechanism.
  
• Obtain a skeletal survey to assess for other fractures in infants suspected of being abused
  

• Elderly are more prone to rib fractures as well as atelectasis, pneumonia, respiratory failure, and other associated complications.
  
• Morbidity and mortality are twice that found in younger populations.
  

DIAGNOSIS