Rosen & Barkin's 5-Minute Emergency Medicine Consult (696 page)

• CXR:
  
  • Pneumonitis
    
  • Pneumonias
    
  • Pleural effusion
    
  • Cardiomegaly
    
• ECG/echocardiogram
  
• CT chest:
  
  • Pulmonary embolus
    
  • Pulmonary hemorrhage
    
  • Diffuse alveolar hemorrhage
    
• CT head for change in mental status or neurologic findings (lupus cerebritis is a diagnosis of exclusion)
  

• Pregnancy is not recommended during active disease owing to the high risk of spontaneous abortion
  
• The effect of pregnancy on disease activity is variable
  

• Hypotension in the known lupus patient may be due to shock from a major flare-up, secondary to acute steroid withdrawal, or the result of sepsis
  
• Other autoimmune diseases:
  
  • Rheumatic fever
    
  • Rheumatoid arthritis
    
  • Dermatomyositis
    
  • Overlap syndromes
    
• Skin changes:
  
  • Urticaria
    
  • Erythema multiforme
    
• Idiopathic thrombocytopenic purpura
  
• Multiple sclerosis
  
• Epilepsy
  

TREATMENT

ABCs

• Mainstays include NSAIDs, corticosteroids, antimalarials, and immunosuppressive drugs
  
• Special attention must be given to CNS and renal involvement as well as infections; these are the main determinants of morbidity
  
• Mild flare-ups
  —
  arthralgias, myalgias, fatigue, and rash:
  
  • NSAIDs (careful with lupus nephritis), acetyl salicylic acid (ASA), topical steroids for rash, sunscreen
    
  • Topical steroids for most cutaneous manifestations
    
  • If not sufficient, begin low-dose prednisone
    
• Major flare-ups
  —
  life- or organ-threatening:
  
  • Methylprednisolone
    
  • Anticoagulation for thrombosis; give blood products early if needed
    
  • Psychotropics for neuropsychiatric symptoms
    
  • Anticonvulsants for seizures
    
  • If poor response, consult rheumatology before starting cytotoxic medications
    
• Chronically:
  
  • Prednisone taper
    
  • NSAIDs
    
  • Rheumatologist initiated:
    
    • Antimalarials: Quinacrine, chloroquine:
      
      • Side effect is irreversible retinopathy
        
    • Cyclophosphamide
      
    • Azathioprine
      
    • Methotrexate
      
    • Belimumab (FDA approved for active, autoantibody positive disease in patients under active treatment)
      
  • Hormonal therapy, mycophenolate mofetil, rituximab, and autologous marrow stem cell transplant are under investigation
    

• Methylprednisolone: 15 mg/kg/d IV up to 1 g; consult rheumatologist for peds dosing
  
• Prednisone: 5–30 mg (peds: <0.5 mg/kg) PO daily for minor flare
  
• Prednisone: 1–2 mg/kg/d PO for major flares in adults
  
• Ibuprofen: 800 mg (peds: 5–10 mg/kg) PO TID
  

FOLLOW-UP

• Patients who have end-organ disease such as renal, cardiac, or CNS involvement
  
• Thrombocytopenia with hemorrhage, arterial or venous thrombosis
  
• Consider admission with pericarditis, myocarditis, pleural effusion or infiltrates, and evidence of vasculitis
  
• Those with severe end-organ or life-threatening manifestations should be admitted to the ICU
  
• Patients with lupus should be treated as immunocompromised and suspected or diagnosed infections should be treated aggressively
  

• Patients may be discharged home with mild flare-ups if afebrile, well hydrated, and not ill appearing
  
• ESR should not be used as disposition criterion as it may be elevated long after a flare-up has subsided
  

Because lupus is a chronic disease, a rheumatologist or knowledgeable primary care physician (PCP) must follow the patient adequately

PCPs must educate patients regarding sun protection, immunizations, and lowering risks of atherosclerosis

• The diagnosis of SLE is complicated and requires a thorough history and physical exam supported by appropriate lab testing
  
• Chronic steroid therapy leads to immunosuppression
  
• Renal involvement confers a poor prognosis
  
• Serum creatinine may be elevated, but is a poor indicator of the disease (urinalysis is more sensitive with proteinuria and/or red blood cell casts)
  
• All patients with SLE should be offered annual, seasonal influenza vaccinations and be sure that pneumococcal vaccination is up to date
  
• VDRL may be falsely positive
  

• Buyon JP. Systemic lupus erythematosus: Clinical and laboratory features. In: Klippel JH, ed.
  Primer on the Rheumatic Diseases
  . 13th ed. Atlanta: Arthritis Foundation; 2008:303–318.
  
• Coca A, Sanz I. Updates on B-cell immunotherapies for systemic lupus erythematosus and Sjogren’s syndrome.
  Curr Opin Rheumatol
  . 2012;24:451–456.
  
• Lehrmann J, Sercombe CT. Systemic lupus erythematosus and the vasculitides.
  Rosen’s Emergency Medicine.
  7th ed. Philadelphia, PA: Mosby Elsevier; 2010.
  
• Schur PH, Wallace DJ. Overview of the therapy and prognosis of systemic lupus erythematosus in adults.
  UptoDate.com
  . Available at
  http://utdol.com/
  .
  

CODES

• 420.0 Acute pericarditis in diseases classified elsewhere
  
• 583.81 Nephritis and nephropathy, not specified as acute or chronic, in diseases classified elsewhere
  
• 710.0 Systemic lupus erythematosus
  

BASICS

• Any disturbance of the heart’s rhythm resulting in a rate >100 bpm
  
• Sinus tachycardia:
  
  • Narrow complex regular rhythm at a rate of 100–150 bpm
    
  • Max. rate typically 220 minus age
    
  • Functional response to physiologic stress caused by increased catecholamine tone or decreased vagal stimulation
    
• Supraventricular tachycardia (SVT):
  
  • A narrow complex tachycardia that originates above the His bundle
    
• Regular SVT:
  
  • Atrial tachycardia
    
  • Junctional tachycardia:
    
    • Regular tachycardia without preceding depolarization waves
      
• Irregular SVT:
  
  • Atrial fibrillation (AF)
    
  • Atrial flutter
    
  • Multifocal atrial tachycardia
    
• Ventricular tachycardia (VT):
  
  • ≥3 consecutive ventricular ectopic beats at a rate of 100 bpm
    
  • Most common initiating rhythm in sudden death in patients with previous MI
    
• Torsades de pointes:
  
  • Paroxysmal form of VT with undulating axis and prolonged baseline QT interval
    
  • Secondary to either congenital or acquired abnormalities of ventricular repolarization
    
  • Often the result of drug therapy or electrolyte disturbances
    
• VF:
  
  • Oscillations without evidence of discrete QRST morphology
    
  • Accounts for 80–85% of sudden cardiac deaths
    
  • Frequently results from degeneration of sustained VT
    

• Sinus tachycardia:
  
  • Acute MI
    
  • Anemia
    
  • Anxiety
    
  • CHF
    
  • Drug intoxication
    
  • Hyperthyroidism
    
  • Hypovolemia
    
  • Hypoxia
    
  • Infection
    
  • Pain
    
  • Pericardial tamponade
    
  • Pulmonary embolus
    
• Atrial tachycardia:
  
  • Precipitated by a premature atrial or ventricular contraction
    
  • Electrolyte disturbances
    
  • Drug toxicity
    
  • Hypoxia
    
• Junctional tachycardia:
  
  • AV nodal re-entry
    
  • Myocardial ischemia
    
  • Structural heart disease
    
  • Pre-excitation syndromes
    
  • Drug and alcohol toxicity
    
• AF:
  
  • HTN
    
  • Coronary artery disease
    
  • Hyper-/Hypothyroidism
    
  • Alcohol intake
    
  • Mitral valve disease
    
  • Chronic obstructive pulmonary disease
    
  • Pulmonary embolus
    
  • Wolf–Parkinson–White (WPW) syndrome
    
  • Hypoxia
    
  • Digoxin toxicity
    
  • Chronic pericarditis
    
  • Idiopathic AF
    
• Atrial flutter:
  
  • Ischemic heart disease
    
  • Valvular heart disease
    
  • CHF
    
  • Myocarditis
    
  • Cardiomyopathies
    
  • Pulmonary embolus
    
  • Electrolyte abnormalities
    
  • Recent cardiac surgery
    
• Multifocal atrial tachycardia:
  
  • Hypoxic effects of chronic lung disease
    
  • Theophylline toxicity
    
• VT:
  
  • Dilated cardiomyopathy
    
  • Cardiac ischemia
    
  • Hypoxia
    
  • Cardiac scarring/fibrosis
    
  • After cardiac surgery or congenital anomaly repair
    
  • Digoxin toxicity
    
  • Long QT syndrome
    
  • Electrolyte abnormalities
    
• Torsades de pointes:
  
  • Drug toxicity (antiarrhythmic class IA and III agents, antipsychotics, antibiotics, etc.)
    
  • Hypokalemia
    
  • Hypomagnesemia
    
  • Congenital QT prolongation
    
• VF:
  
  • Acute MI (most common)
    
  • Chronic ischemic heart disease
    
  • Hypoxia
    
  • Acidosis
    
  • Anaphylaxis
    
  • Electrocution
    
  • Shock
    
  • Hypokalemia
    
  • Initiation of quinidine therapy
    
  • Massive hemorrhage