• Monitor blood pressure.

Figure 4.4. Algorithm for Management of Hot Swollen Joints. Reproduced with kind permission of the BSR and Oxford University Press.

• Gain intravenous access.

• Obtain venous blood sample for FBC, U&E, LFTs, ESR and CRP.

• If signs of sepsis are present: ^ summon help

^ follow sepsis management at the beginning of this chapter.

• Obtain blood cultures.

• Record temperature.

• Do not commence antibiotic therapy until synovial fluid has been aspirated.

• If you have not already done so, refer patient to orthopaedics or rheumatology depending on local policy as they require synovial fluid aspiration.


• Assess level of consciousness using AVPU.

• Exam the affected joint and all other joints for signs of inflammation.

• Obtain plain x-ray of the affected joint.


• If you have not already done so obtain a detailed history.

• Examine all other joints for signs of swelling and tenderness.

• Ensure that expert help is on its way to undertake synovial fluid aspiration. This should be Gram-stained and cultured.

• Once aspiration has been performed antibiotic therapy can be commenced.


Antibiotics should be commenced in accordance with local policy. However, the BSR has issued some guidance for the suggested antibiotic regimen.

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