Rheumatological Emergencies in the ICU

Your progress

Saved on this device.

Target exams

Red flags

• Scleroderma renal crisis: sudden malignant hypertension + AKI + microangiopathic haemolysis in systemic sclerosis = START AND UPTITRATE AN ACE INHIBITOR IMMEDIATELY — this is the ONE intervention that changes outcome
• Anti-MDA5 dermatomyositis: rapidly progressive ILD (within days-weeks) with high mortality — high-dose steroids + calcineurin inhibitor ± cyclophosphamide early — check anti-MDA5 and ferritin in ANY patient with rapidly progressive ILD + Gottron papules/mechanic's hands
• Neuropsychiatric lupus: seizures, psychosis, transverse myelitis, or cognitive dysfunction in SLE = pulse methylprednisolone + cyclophosphamide — distinguish from steroid-induced neuropsychiatric effects (dose-related, recover when the steroid dose falls)
• Atlantoaxial subluxation in RA: neck pain + neurological symptoms + RA = flexion-extension X-ray/MRI BEFORE intubation — in-line stabilisation during laryngoscopy — anterior subluxation can compress spinal cord during neck extension for intubation
• Cricoarytenoid arthritis in RA: hoarseness + stridor + RA = difficult airway — fiberoptic intubation preferred — cricothyroidotomy may be anatomically distorted
• Systemic sclerosis + refractory hypoxaemia: screen for pulmonary arterial hypertension with annual echo (SSc accounts for most CTD-associated PAH) — right heart catheter for confirmation
• DO NOT withhold ACE inhibitor in scleroderma renal crisis even if creatinine rises — with ACE inhibitors 1-year survival is 76% versus 15% without, and over half of patients still on dialysis after 3 months who continue the ACE inhibitor come off dialysis — a rising creatinine is NOT a reason to stop