Rosen & Barkin's 5-Minute Emergency Medicine Consult (78 page)

• Cefazolin: 1–2 g IV q6h
  
• Ceftazidime: 1–2 g IV q8h
  
• Cefotaxime: 2 g IV q8h; peds: 50 mg/kg q12h
  
• Ceftriaxone:2 g IV QD; peds: 50 mg/kg
  
• Ciprofloxacin: 400 mg IV q12h
  
• Flucloxacillin: 2 g QD IV
  
• Gentamicin: 2–5 mg/kg IV load
  
• Nafcillin: 2 g IV q4h; peds: 25 mg/kg q6h
  
• Tobramycin: 1 mg/kg IV q8h; peds: 2.5 mg/kg q8h
  
• Vancomycin: 1 g IV q12h; peds: 10 mg/kg q6h
  

• Open surgical drainage is the method of choice in pediatric hip SA.
  
• Cover
  H. influenzae
  type B if prior immunization cannot be established.
  

FOLLOW-UP

• All patients with suspected SA should be admitted until SA is ruled out.
  
• May undergo drainage of joint, as indicated, by serial aspirations, arthroscopy, or arthrotomy
  

Cases where suspected SA has been adequately ruled out

• CRP and ESR can be used to follow up response to treatment
  
• It can be difficult to distinguish SA from toxic synovitis or crystal arthropathy; have a low threshold for arthrocentesis.
  

• Carpenter CR, Schuur JD, Everett WW, et al. Evidence-based diagnostics: Adult septic arthritis.
  Acad Emerg Med
  . 2011;18:781–796.
  
• Coakley G, Mathews C, Field M, et al. BSR & BHPR, BOA, RCGP and BSAC guidelines for management of the hot swollen joint in adults.
  Rheumatology
  . 2006;45:1039–1041.
  
• Mathews CJ, Weston VC, Jones A, et al. Bacterial septic arthritis in adults.
  Lancet
  . 2010;375:846–855.
  
• Rosey AL, Abachin E, Quesnes G, et al. Development of a broad-range 16S rDNA real-time PCR for the diagnosis of septic arthritis in children.
  J Microbiol Methods
  . 2007;68:88–93.
  
• Shen CJ, Wu MS, Lin KH, et al. The use of procalcitonin in the diagnosis of bone and joint infection: A systemic review and meta-analysis.
  Eur J Clin Microbiol Infect Dis
  . 2013;32(6):807–814.
  
• Weisfelt M, van de Beek D, Spanjaard L, et al. Arthritis in adults with community-acquired bacterial meningitis: A prospective cohort study.
  BMC Infect Dis
  . 2006;6:64.
  

CODES

• 711.00 Pyogenic arthritis, site unspecified
  
• 711.05 Pyogenic arthritis, pelvic region and thigh
  
• 711.45 Arthropathy associated with other bacterial diseases, pelvic region and thigh
  

BASICS

• Pathologic accumulation of serous fluid in the peritoneal cavity
  
• Portal hypertension (>12 mm Hg) starts fluid retention.
  
• Avid sodium retention state
  
• Retained sodium and water increases plasma volume.
  
• Water excretion becomes impaired.
  
• Increased release of antidiuretic hormone (ADH)
  
• Urinary sodium retention, increased total body sodium, and dilutional hyponatremia
  
• Degree of hyponatremia correlates with disease severity; prognostic factor.
  
• Decreased plasma oncotic pressure from hypoalbuminemia
  
• Peritoneal irritation owing to infection, inflammation, or malignancy
  

• Parenchymal liver disease:
  
  • Cirrhosis and alcoholic hepatitis:
    
    • 80% of adult patients
      
  • Fulminant hepatic failure
    
• Hepatic congestion:
  
  • CHF
    
  • Constrictive pericarditis
    
  • Veno-occlusive disease and Budd–Chiari syndrome
    
• Malignancies:
  
  • Peritoneal carcinomatosis
    
  • Hepatocellular carcinoma or metastatic disease
    
• Infections:
  
  • TB, fungal, or bacterial peritonitis
    
• Hypoalbuminemic states:
  
  • Nephrotic syndrome
    
  • Malnutrition; albumin <2.0 g/dL
    
• Other conditions:
  
  • Pancreatic ascites
    
  • Biliary ascites
    
  • Nephrogenous ascites
    
  • Ovarian tumors
    
  • Chylous ascites from lymphatic leak
    
  • Connective tissue disease
    
  • Myxedema
    
  • Granulomatous peritonitis
    

Most pediatric cases owing to:

• Malignancy (Burkitt lymphoma, rhabdomyosarcoma)
  
• Nephrotic syndrome
  
• Malnutrition
  

DIAGNOSIS

• Abdominal distention, discomfort
  
• Weight gain; sometimes weight loss
  
• Dyspnea
  
• Orthopnea
  
• Edema
  
• Abdominal hernias
  
• Muscle wasting
  
• Shifting dullness, flank fullness, fluid wave, puddle sign
  
• Signs and symptoms of underlying disease
  
• Stigmata of chronic liver disease
  

• Risk factors for liver disease
  
• Description of onset of symptoms:
  
  • Distinguishes ascites from obesity
    
  • Patients less tolerant of rapid accumulation of ascitic fluid
    
• New-onset ascites in known cirrhotic signifies 1 of the following:
  
  • Progressive liver disease
    
  • Superimposed acute liver injury (alcohol, viral hepatitis)
    
  • Hepatocellular carcinoma
    

• Detection difficult in obese patients
  
• Flank dullness is a prominent physical finding:
  
  • 500 mL for flank dullness
    
  • Fluid wave
    
  • Shifting dullness
    

• Search for liver disease, CHF, TB, malignancy, and other systemic disorders.
  
• Abdominal paracentesis:
  
  • Necessary for:
    
    • New ascites
      
    • Worsening encephalopathy
      
    • Fever
      
    • Abdominal pain/tenderness
      
• Determine if fluid infected or presence of portal hypertension
  
• Test ascitic fluid for:
  
  • Cell count and differential:
    
    • Most helpful to determine infection quickly
      
    • Order on every specimen
      
  • Albumin
    
  • Protein
    
  • Gram stain
    
  • Culture twice in blood culture bottles with 10 mL of fluid
    
  • Lactate dehydrogenase (LDH)
    
  • Glucose
    
  • TB culture
    
  • Amylase
    
  • Triglyceride
    
  • Cytology
    
  • Bilirubin
    
  • Carcinoembryonic antigen
    
• Spontaneous bacterial peritonitis (SBP):
  
  • Ascitic fluid infection without an intra-abdominal surgically treatable source
    
  • Fever, abdominal pain/tenderness, altered mentation
    
  • Polymorphonuclear neutrophils (PMNs) >250 cells/mm
    ³
    
  • Ascitic fluid protein <1 g/dL
    
  • Low concentration of opsonins
    
• Secondary bacterial peritonitis:
  
  • Bacterial peritonitis from a surgically treatable intra-abdominal source
    
  • Gut perforation or intra-abdominal abscess (i.e., perinephric abscess)
    
  • PMNs >250 cells/mm
    ³
    with multiple micro-organisms on Gram stain + 2 of the following found with secondary bacterial peritonitis:
    
    • Total protein >1 g/dL
      
    • Glucose <50 mg/dL
      
    • LDH greater than the upper limit of normal for serum
      

• CBC
  
• Basic chemistry
  
• LFTs
  
• PT, PTT, INR
  
• Arterial blood gas (ABG) or pulse oximeter
  
• Urinalysis
  
• Urine sodium
  
• Hepatitis panel
  
• Amylase/lipase
  
• α-fetoprotein
  
• TSH
  

• US:
  
  • Confirm ascites, especially if <500 mL
    
  • Evaluate liver, pancreas, spleen, and ovaries
    
  • Guides paracentesis
    
• Doppler study: Evaluate hepatic blood flow
  
• CT scan
  
• CXR: CHF, effusions, cavitary, or mass lesion
  
• ECG
  

• Peritoneoscopy: Ascites of unknown cause; especially TB
  
• Paracentesis:
  
  • Clinical diagnosis of SBP without paracentesis is inadequate.
    
  • Safety of paracentesis:
    
    • 70% of ascitic patients have coagulopathy.
      
    • Benefits of a diagnostic paracentesis outweigh the risks.
      
    • Paracentesis is still indicated unless disseminated intravascular coagulation (DIC) is present.
      
    • Transfusion of plasma or platelets prior to paracentesis is not supported.