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The Patient with Rheumatoid Arthritis in the ED

Rob Orman, MD, Mel Herbert, MD MBBS FAAEM, and Samantha Berman, MD
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20:48
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN
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03:18

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EM:RAP 2018 04 April Written Summary 535 KB - PDF

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Mike J., M.D. -

A nit to pick. Your discussion of synovial lactate suggested that a lactate of <10 excluded septic arthritis, the implication was of a -LR of 0. This is misleading. Most of the evidence is clear that a joint fluid lactate of >10 identifies those with septic arthritis but the converse, a lactate of <10 in no way excludes the diagnosis. There is, in fact very little data to determine what the lower level of synovial lactate is, that would exclude septic arthritis.

Currently I think we must continue to use synovial lactate as a one way test. It can rule in, but it cannot rule out.

Stuart S., MD FAAEM -

Mike: Thank you so much for your comment! Your approach seems prudent to me - and I agree. In fact, we are planning to revisit the evidence for synovial lactate in the workup of septic arthritis in the near future...

Gerold K. -

Thanks, great! Just a question:
RA patient on more or less chronic steroid therapy, presenting with sepsis, should they get a burst of steroids? Just assuming they are adrenal compromized and under increases stress due to the infection, unable to produce enough corticosteroids by themselves.

Stuart S., MD FAAEM -

Gerold: This is a great question. In general, I consider giving "stress dose" steroids in patients that are on long term steroid therapy that might suppress their own endogenous secretion of corticosteroids. These patients may not respond to fluid resuscitation and vasopressors until steroids are administered. Hydrocortisone or dexamethasone are commonly used empirically.

Yves G. -

I didn't find any good study to make my mind on the subject. Can you tell me where does that come from ?

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EM:RAP 2018 April Full episode audio for MD edition 204:44 min - 285 MB - M4AEM:RAP 2018 April German Edition Deutsche 95:30 min - 131 MB - MP3EM:RAP 2018 April Canadian Edition Canadian 32:00 min - 44 MB - MP3EM:RAP 2018 April Aussie Edition Australian 14:16 min - 21 MB - MP3EM:RAP 2018 April French Edition Français 25:04 min - 35 MB - MP3EM:RAP 2018 April Spanish Edition Español 84:00 min - 115 MB - MP3EM:RAP 2018 04 April Board Review Answers 100 KB - PDFEM:RAP 2018 04 April Board Review Questions 97 KB - PDFEMRAP 2018 04 April Individual MP3 Files 258 MB - ZIPEMRAP 2018 04 April Individual Written Summaries 657 KB - ZIPEM:RAP 2018 04 April Spanish Written 1 MB - PDFEM:RAP 2018 04 April Written Summary 535 KB - PDF

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