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stevens johnson syndrome...without a rash

STEVENS-JOHNSON SYNDROME:
--severe idiosyncratic reactions, most commonly triggered by medications, which are characterized by fever and mucocutaneous lesions leading to necrosis and sloughing


--less severe disease on the same spectrum as TEN (toxic epidermal necrolysis)


DIAGNOSIS: NOT FAIR
--apparently, you can have Stevens-Johnson syndrome without a rash


PMID:  22041607
The Stevens-Johnson syndrome (SJS) classically involves a rash, conjunctivitis and mucositis.

case report of isolated mucositis and conjunctivitis.

Previous rare reports of severe SJS like syndromes without a rash are confined to children, usually with mycoplasma pnemoniae infection


PMID:  22012144
The commonest infections associated with SJS have been HSV and Mycoplasma pneumoniae. 

Less than 10% cases of Mycoplasma pneumonia develop extra pulmonary complications like hemolytic anemia, hepatitis, arthritis, meningitis and SJS.  

unclear from existing literature whether antibiotic treatment of M. pneumoniae infection decreases the risk for SJS. 


PMID:  20678095
another case report of mucocutaneous involvement without skin lesions. 

Oral lesions are present in all cases with SJS associated with M. pneumoniae infection, ocular lesions only in two-thirds and genital lesions in three-fourths of all cases. 

That SJS in association with M. pneumoniae infection is predominantly mucosal is reflected by few reports of SJS presenting without skin lesions. Even when skin lesions are present, mucocutaneous lesions predominate.


BOTTOM LINE:
--stevens johnson syndrome: skin and mucosal involvement, can progress to sloughing (e.g. TEN)
--can present withOUT rash. Mycoplasma pneumonia is common source.


Submitted by J. Gullo.




Reference(s): uptodate.com: Stevens-Johnson syndrome and toxic epidermal necrolysis: Clinical manifestations; pathogenesis; and diagnosis; article 1, article 2, article 3; picture

when not to use succinylcholine

BLATANT REDIRECT:

--check out EMCrit's handy slide

--good quick review of when you can (or can't) use succinylcholine

BOTTOM LINE:

--check out the slide on EMCrit

--if you can't or are lazy, remember succinylcholine causes K+ release

--also, hyperkalemia is bad

--first do no harm

Reference(s): emcrit.org; picture

loop abscess

Looking for a fun and interesting new way to treat an abscess?

(I've done it once, with good success.)

You tube video - only 2 minutes long, worth watching, and worth reviewing in the ED before actually trying this:

Dr. Tsoriades and colleagues found using a vessel loop (see picture) was a safe and effective treatment for subcutaneous abscesses in children when studied in comparison with traditional incision and drainage with packing. 

Children in the study were under general anesthesia or conscious sedation. (I used a traditional field block using 2% lidocaine with epinephrine in an adult.)

Pros:

• no repeat packing
• better tolerated by patients
• less wound care materials
• much smaller incision - less scarring

Discharge instructions:

• apply warm compresses
• expect drainage
• move loop back and forth 2 times daily 
• return if worse/fever/increasing redness

Submitted by S. Morris.

Reference(s): A.P. Ladd, M.S. Levy, J. Quilty. Minimally invasive technique in treatment of complex, subcutaneous abscesses in children. J Pediatr Surg, 45 (2010), pp. 1562–1566;  S.S. Tsoraides, R.H. Pearl, A.B. Stanfill, L.J. Wallace, R.K. VeguntaIncision and loop drainage: A minimally invasive technique for subcutaneous abscess management in children J Pediatr Surg, 45 (2010), pp. 606–609; picture

laws of the house of god

from THE HOUSE OF GOD, by Samuel Shem, M.D.
--haven't read this in a few years, but came upon this list again recently.
--my favorites are #'s 3 & 6.
--enjoy

1. GOMERS DON’T DIE.
2. GOMERS GO TO GROUND.
3. AT A CARDIAC ARREST, THE FIRST PROCEDURE IS TO TAKE YOUR OWN PULSE.
4. THE PATIENT IS THE ONE WITH THE DISEASE.
5. PLACEMENT COMES FIRST.
6. THERE IS NO BODY CAVITY THAT CANNOT BE REACHED WITH A #14G NEEDLE AND A GOOD STRONG ARM.
7. AGE + BUN = LASIX DOSE.
8. THEY CAN ALWAYS HURT YOU MORE.
9. THE ONLY GOOD ADMISSION IS A DEAD ADMISSION.
10. IF YOU DON’T TAKE A TEMPERATURE, YOU CAN’T FIND A FEVER.
11. SHOW ME A BMS (Best Medical Student, a student at the Best Medical School) WHO ONLY TRIPLES MY WORK AND I WILL KISS HIS FEET.
12. IF THE RADIOLOGY RESIDENT AND THE MEDICAL STUDENT BOTH SEE A LESION ON THE CHEST X-RAY, THERE CAN BE NO LESION THERE.
13. THE DELIVERY OF GOOD MEDICAL CARE IS TO DO AS MUCH NOTHING AS POSSIBLE.  

Reference(s): thanks, dr. wikipedia; picture

Antibiotics for MRSA abscesses? NO.

STUDY #1:

Schmitz et al. Randomized Controlled Trial of Trimethoprim-Sulfamethoxazole for Uncomplicated Skin Abscesses in Patients at Risk for Community-Associated Methicillin-Resistant Staphylococcus aureus Infection. Annals of Emergency Medicine, Vol 56, Sept 2010

Bactrim vs. placebo after incision and drainage.  

Multicenter, double-blind, RCT in 4 military ED's

outcome: treatment failure after 7 days or reduction of new lesion formation in 30 days

results:

                        Tx failure 7 days              New lesion within 30 days      

Placebo                     26%                                          28%

TMP/SMX                  17%                                           9%

Difference (95%CI)      9% (-2 to 21%)                         19% (4-34%)

As shown above, there was a significant difference of new lesions in 30 days.  only 45% were available at 30 days.  big confidence intervals.

STUDY #2

Duong et al. Randomized, Controlled Trial of Antibiotics in the Management of Community-Acquired Skin Abscesses in the Pediatric Patient. Annals of Emergency Medicine, Vol 55, May 2010

Bactrim vs. placebo after incision and drainage. 

double-bind RCT in pediatric patients

outcome: treatment failure within 10 days (need for second incision, IV antibiotics, continued erythema, warmth, fluctuance at 10 day follow up).

results:

              Failure to improve            10 day new lesions    90 day new lesions**
Placebo          5.3%                         26.4%                     28.8%
TMP/SMX       4.1%                         12.9%                     28.3%

** Note that only around 60% were effectively followed up at 90 days.

Conclusion: no difference in failure rates with or without antibiotics. 

Of note,  in treatment arm, only 46% of patients were compliant with antibiotics, taking at least half of the pills. 

Note that there are many other studies showing that antibiotic use does NOT eradicate MRSA.

BOTTOM LINE:

Immunocompetent patients with MRSA abscesses can be treated with I & D alone. Not enough data to support consistent antibiotic use. 

Consider addition of antibiotics in diabetics, immunocompromised, or systemically ill. 

Submitted by S. Morris.

Reference(s): study 1, study 2, picture

passive preoxygenation - a radical concept

Next time you intubate someone...

consider putting them on a nasal cannula at 15L per min under the NRB.  

this article advocates it as a form of "apneic oxygenation" which can prevent desaturation during intubation. 

Awake patients will not tolerate it at 15L/min, so you can start with 4-5 L and then increase to 15 after giving your induction and paralytic medications.

The point: Apneic oxygenation can extend the duration of safe apnea.

Note: High O2 could decrease the respiratory drive, but this is for people who you are committed to intubating already.  

I would love to hear your success stories with this new method!

Submitted by S. Morris.

Reference(s): Weingart, S., Levitan, R.  Preoxygenation and Prevention of Desaturation During Emergency Airway Management. Annals of Emergency Medicine. Nov 2011. Vol 9. Iss 3. ; picture