Dermatological emergencies : Stevens-Johnson Syndrome

February 15, 2021February 19, 2021 ~ Sumaiya Hafiz, UAE ~ Leave a comment

Every medical student has three categories of topic division

Category 3 catches you by surprise when it makes it an entry in the ED and serves as a reminder of why it is essential always to know something about everything. Stevens-Johnson Syndrome was one of those for me. Although rare, dermatological emergencies are essential to spot and can be life-threatening if left untreated.

Stevens-Johnsons Syndrome is a rare type 4 hypersensitivity reaction which affects <10% of body surface area. It is described as a sheet-like skin loss and ulceration (separation of the epidermis from the dermis).

Toxic epidermal necrosis and Stevens-Johnsons Syndrome can be mixed. However, distinguishing between both disease can be done by looking at % of body surface area involvement.

< 10% BSA = Stevens-Johnsons Syndrome
10-30% BSA = Stevens-Johnsons Syndrome/Toxic epidermal necrosis overlap syndrome
> 30%= Toxic epidermal necrosis – above image is an example of toxic epidermal necrosis.

Pathophysiology is unknown

Pathophysiology is not clearly known; however, some studies show it is due to T cells’ cytotoxic mechanism and altered drug metabolism.

Causes

The most common cause of Stevens-Johnsons Syndrome is medications. Examples are allopurinol, anticonvulsants, sulfonamide, antiviral drugs, NSAIDs, salicylates, sertraline and imidazole.

As one of the commonest cause is drug-induced, it is a vital part of history taking. Ask direct and indirect questions regarding drug intake, any new (started within 8 weeks) or old medications and previous reactions if any.

Other causes are malignancy and infections (Mycoplasma pneumonia, Cytomegalovirus infections, Herpesvirus, Hep A).

Risk Factors

The disease is more common in women and immunocompromised patients (HIV, SLE)

Clinical Presentations

Flu-like symptoms(1-14 symptoms)
Painful rash which starts on the trunk and spreads to the face and extremities.
Irritation in eyes
Mouth ulcers or soreness

Clinical Exam Findings

Skin manifestation – Starts as a Macular rash that turns into blisters and desquamation.
An important sign in SJS is Nikolsky’s sign: It is considered positive if rubbing the skin gently causes desquamation.
2 types of mucosa are involved in SJS – oral and conjunctiva, which precede skin lesions.
Other findings in the examination may include –
Oral cavity – ulcers, erythema and blisters
Cornea – ulceration

Diseases with a similar presentation – in children, staphylococcal scalded skin syndrome can be suspected as it has a similar presentation and can be differentiated with the help of a skin biopsy.

Diagnosis

Clinical awareness and suspicion is the cornerstone step for diagnosis. Skin Biopsy shows subepidermal bullae, epidermal necrosis, perivascular lymphocytic infiltration, which help for definitive diagnosis.

Management

Adequate fluid resuscitation, pain management and monitoring of electrolytes and vital signs, basic supportive or resuscitative actions are essential, as with any emergency management.

The next step is admitting the patient to the burn-unit or ICU, arranging an urgent referral to dermatology and stopping any offending medications. If any eye symptoms are present, an ophthalmology referral is required.

Wound management is essential- debridement, ointments, topical antibiotics are commonly used to prevent bacterial infections and ease the symptoms.

Complications

Liver, renal and cardiac failure
Dehydration
Hypovolemic or septic shock
Superimposed infection
Sepsis
Disseminated intravascular coagulation
Thromboembolism
Can lead to death if left untreated

Prognosis

Prognosis of a patient with Stevens-Johnson Syndrome is assesed by the SCORTEN Mortality Assesment Tool. Each item equal to one point and it is used within the 24 hours of admission.

• Age >/= 40 years (OR 2.7)
• Heart Rate >/= 120 beats per minute (OR 2.7)
• Cancer/Hematologic malignancy (OR 4.4)
• Body surface area on day 1; >10% (OR2.9)
• Serum urea level (BUN) >28mg/dL (>10mmol/L) (OR 2.5)
• Serum bicarbonate <20mmol/L (OR 4.3)
• Serum glucose > 252mg/dL (>14mmol/L) (OR5.3)

Predicted mortality based on the above total:

0-1 Point = 3.2%
2 Points = 12.1%
3 Points = 35.3%
4 Points = 58.3%
5 Points = 90.0%

References and Further Reading

Dermatological Emergencies

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis

https://em3.org.uk/foamed/3/6/2019/lightning-learning-stevens-johnson-syndrome

Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in Pediatric Population

https://wikem.org/nw/index.php/Stevens-Johnson_syndrome_and_toxic_epidermal_necrolysis

Cite this article as: Sumaiya Hafiz, UAE, "Dermatological emergencies : Stevens-Johnson Syndrome," in International Emergency Medicine Education Project, February 15, 2021, https://iem-student.org/2021/02/15/stevens-johnson-syndrome/, date accessed: June 1, 2023

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Triads in Medicine – Rapid Review for Medical Students

June 12, 2020June 7, 2020 ~ Sumaiya Hafiz, UAE ~ Leave a comment

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

How to make the most of your EM Clerkship

October 4, 2019October 4, 2019 ~ Sumaiya Hafiz, UAE ~ Leave a comment

Emergency Medicine has something for everyone!

Starting the Emergency Medicine (EM) Clerkship is one of the most exciting times of any medical student’s life, regardless of whichever specialty they plan on specializing in because EM has something for everyone. It is like solving all those questions that begin with ‘A patient presents to the Emergency Department with…’ but in reality, at a faster pace and with more tricky situations. This can make students feel overwhelmed, as they find themselves juggling between books and resources as to which one to follow or which topics to learn, and I am here for just that! To share the approach that helps many students get the hang of EM and make the most of their time in one of the best learning environments of any hospital.

Prepare a list of common conditions

The basic approach would be first to jot down all the problems you can think of.

Here is a list to help you get started: Core EM Clerkship Topics

core em clerkship topics

There are problems that you may be heard a lot such as Chest Pain, Heart Failure, Shock (and it’s types), Acute Coronary Syndrome, Sepsis, Pulmonary edema, Respiratory Failure, Coma, Stroke, Hypoglycemia, Subarachnoid Hemorrhage, Fractures, Head Trauma, Status Epilepticus, Diabetic Ketoacidosis, and Anaphylaxis.

As every doctor you meet will always say, common is common, so always focus on things that you have heard and seen most about, read about them, make notes on their clinical features, differentials, investigations and management. Most importantly, do not forget to read about the ABCDE approach in every critically ill and trauma patient.

Brush up on your history taking and examination skills

Know what to ask and when to ask. Patients in the ED are not in their most comfortable composure, so try to practice and frame questions that provide you with just enough information to make a diagnosis in the least possible time.
The same goes for examination, never forget the basics of examination and their importance. Practice examination as much as you can and you will automatically see it come to you naturally at a faster pace. Also, do not forget focused history and physical examination is a cornerstone of EM practice and saves a lot of time.
Where investigations can help you exclude a differential, 80% of your diagnosis will be built from what you ask, what you see and what you feel. Keep in mind that if you are not thinking or looking for something, you will not see and find it. So, be suspicious of life, organ and limb-threatening problems.

Read about common ED procedures

ABG, Intubation, Central Lines, FAST Scan, Suturing, Catheter and Cannula placement are some of them. As a medical student, you will probably not be required to perform any, but it is good to have an idea about the procedures when you see them. If you can practice, then that is even better, ask a resident or intern to show you how and you can have a go yourself under their supervision! Remember, “see one, do one, teach one.”

list of selected procedures

Watch videos on examination, interpreting X-rays, & procedural skills

Youtube is an asset when it comes to medical education, make good use of it. There are also plenty of videos on the iEM website that you can watch and learn from.

Interpretation of ECG & X-rays

Google is your best friend for this! You have the list of common conditions, all you need to do is a google search on the most common ECG findings and x-rays in medical emergencies and you will be good to go. You can also always learn these from the doctors around you in the ED, as the more you see and try to interpret, the better you get at differentiating the normal from abnormal.

How to read c-spine x-rays

How to read chest x-rays

How to read pelvic x-ray

Books

Before the rotation

Before the rotation, read a review book, recall your basic knowledge from internal medicine/family medicine and surgery because EM almost covers all of the acute problems of those fields. Moreover, do not forget, EM is an independent specialty and has its’ own textbooks.

iEM Clerkship book is a very good source to get started with! Download Now! – iEM Book (iBook and pdf)

If you are the kind, who likes solving questions, the Pretest Emergency Medicine is a great source.

FREE DOWNLOAD

During the rotation

During the rotation – Learning what you see is the best way to keep things in your long term memory. After your shift ends, and you go home, get some rest, recall the cases of the day and read about them on Up to Date/ Medscape or any resource that you prefer, this will help you relate what you saw with what you are reading and will help you recall it better later on.

These are just a few tips to help in making the most of your EM rotation. Remember to study hard, but also practice, brush up on your communication skills, talk to patients, be there for them. The EM Clerkship prepares you for life as a doctor, as you practice every aspect of medicine during this time and learn to answer questions about acute medical problems and their severity when asked by those around you.

Cite this article as: Sumaiya Hafiz, UAE, "How to make the most of your EM Clerkship," in International Emergency Medicine Education Project, October 4, 2019, https://iem-student.org/2019/10/04/how-to-make-the-most-of-your-em-clerkship/, date accessed: June 1, 2023

An upside-down cake: the EM differential diagnosis

August 26, 2019September 4, 2019 ~ Anthony Rodigin, USA ~ Leave a comment

How we’re different

When I was rotating on surgery as a medical student, our attending once asked of our small group what may be concerning in the differential for right upper quadrant abdominal pain. A very eager and a somewhat brash student blurted immediately: “Echinococcal cyst!” The attending replied, “Well, that’s true, but if Echinococcal cyst is the first thing you think of as a surgical consultant, you’re crazy!”

On the other hand, take a practicing internal medicine physician like my Dad. He formulates his differentials with a very different strategy, which is: what is the most likely? A chronic cough is bronchitis (even with hemoptysis), pneumonia, GERD or postnasal drip. Shoulder pain is, of course, a sprain, bursitis, or some referred cervical impingement. And so on.

Unfortunately, neither hunting for zebras (an unofficial US name for exciting but rare diagnoses) nor settling for the most common works for emergency medicine. In fact, that is how true diagnoses may get missed and patients may start dying.

Why we are different

The EM differential diagnosis is a pyramid tipped on its head. It is therefore different from how differentials are approached by many other specialties.

In EM, we first have to think of and rule out the most severe or threatening pathology. That’s a given. But our choices have to come from among the common killers, not Martian viruses or unheard of tumors from a medical encyclopedia.

Amoebic meningitis is exciting to encounter in your practice. But guess what? Your patient won’t have it. At the same time, for EM physicians things like pulmonary embolus, aneurysm of the abdominal aorta, subarachnoid hemorrhage and necrotizing fasciitis are everyday icons on our cognitive desktops. While less common than a common cold, these things are by no means rare.

Why it is difficult

In EM, one can rest assured that common pathology will present atypically and not quite like the textbook.

Things are further complicated by confounders, mimics and the disjunction of concern.

Confounders are concurrent pathologic processes that the patient already has, which tend to get worse due to any new significant disease process or general body stress. CHF and COPD get exacerbated, kidneys become insufficient, anxiety and psychoses go florid and atrial fibrillation accelerates to rapid. How do you spot sepsis or an MI, which is the true cause of it all, underneath layers and layers of abnormal vitals and test results?

Mimics are things that pretend to be other diseases. PE presenting with a low-grade fever and a cough, carbon monoxide poisoning posing as geriatric altered mental status, and severe sepsis arriving as chest pain, dizziness and a bumped troponin. Such has happened many times in the past and continues to happen daily at all EDs globally.

The disjunction of concern is when your patient is not worried about what you are worried about. They don’t want to get cancer like their neighbor, but they have never heard of a TIA or an AAA. Kawasaki disease? Why don’t you just give my daughter better antibiotics? My uncle died of a heart attack at 35, not a “bisection” or whatever you called it…So I don’t want a CT scan!

An EM physician’s focus on ruling out worst-case scenarios may paradoxically contribute to a patient’s distrust at the end of the encounter. The patient’s agenda is to leave knowing what disease they have, while we are often satisfied knowing which horrible things a patient does do not have.

It may take years of practice to be able to persuade someone that you have done due diligence and your professional duty by excluding a whole lot of deadly things, while the exact diagnosis still remains elusive.

Secretly paranoid, openly confident and always nice

We are confident, but also afraid. We have to think of the worst yet possible scenario for any complaint, yet of course anticipate that the actual diagnosis will hopefully be something less severe and quite common – like a migraine. After all, after most CT scans and lumbar punctures, it is not a subarachnoid hemorrhage.

In EM, we are in this perpetual struggle with having to be professionally pessimistic and paranoid on the one hand, yet emotionally supportive and reassuring for the patient on the other. I always teach my students, even nursing trainees, that no one should be leaving an emergency department more scared or anxious than when they came in.

Your job as a rotating trainee in EM is to understand and learn this exact interplay.

Homework

For your attending, but more importantly for yourself and your patients, you have to be as concerned with sepsis from PID on a 16-year-old young woman with fever and abdominal pain as you are with appendicitis. The 86 year old grandmother with Afib but on no anti-coagulation, because she falls a lot is not just TIA or CVA prone. Her embolic clots may just as well be traveling downstream, causing that intermittent or out of proportion abdominal pain called mesenteric ischemia – for which you do not have a good lab test or imaging, by the way.

Here is a brief checklist:

For any anatomic complaint or a chief complaint type

think of several real worst-case scenarios that are not zebras. Can something horrible yet by no means unheard of be presenting atypically? What steps can you take to prove or disprove it?
Think of confounders and mimics.

What else could be going on? Like a stack of dominoes: what happened first, what happened next?
Address the patient’s concerns

while carefully and patiently pursuing your own professional agenda.
When it turns out to be something common or benign,

don’t forget to discuss worrisome signs for which to return. What if you’re still wrong?

If you liked this story, you may like these too!

Emergency Medicine: A Unique Specialty

R. Rogers, et al.

The Importance of The Emergency Medicine Clerkship

R. Rogers, et al.

Thinking Like an Emergency Physician

J. Lex.

Choosing the Emergency Medicine As A Career

J. Holliman.

Cite this article as: Anthony Rodigin, USA, "An upside-down cake: the EM differential diagnosis," in International Emergency Medicine Education Project, August 26, 2019, https://iem-student.org/2019/08/26/an-upside-down-cake-the-em-differential-diagnosis/, date accessed: June 1, 2023

iEM Weekly Feed 3

July 21, 2018July 20, 2018 ~ iEM Education Project Team ~ Leave a comment

Welcome to iEM Weekly Feed!

With this feed, you do not miss anything. You will find all published blog posts during this week. Click the “title” or “read more” to open each page you interested in.

Pulmonary Embolism

July 14, 2018

by Elif Dilek Cakal Case Presentation A 45-year-old female with no prior medical history presented to the emergency department (ED) with three days of constant shortness

Three days of constant shortness of breath

July 14, 2018

Do you recognize these findings in the US and CT scan? https://youtu.be/Dh-Q23xdqeEhttps://youtu.be/lhops90o6_g Pulmonary Embolism by Elif Dilek Cakal from Turkey. Read Listen

Deep Vein Thrombosis (DVT)

July 14, 2018

by Elif Dilek Cakal Case Presentation An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and swelling of 2

My Leg Is Swollen!

July 15, 2018

A New Chapter Is Just Uploaded To The Website! An 85-year-old woman, with a history of congestive heart failure, presented with right leg pain and

A Little White Coat and A Stethoscope

July 15, 2018

Ibrahim Sarbay Turkey I will never forget the time that I acted as a “medical doctor” at the 1st year-end show of the elementary school.

Fall From Bicycle!

July 16, 2018

In case you didn’t encounter a child fallen from a bicycle today! Read “Multiple Trauma” Chapter Listen “Multiple Trauma” Chapter iEM Education Project Team uploads

Core EM Clerkship Topics

July 16, 2018

Core EM clerkship topics recommended by SAEM are ready for students. Feel free to read or listen. And, do not forget to share with your

Left Flank Pain

July 17, 2018

In case you didn’t encounter flank pain today! iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images

iEM Image and Video Albums

July 17, 2018

Uploading Image and Video Archive More than 350 images and videos are uploaded into iEM Flickr channel. Thousands to come… Uploading Image and Video Archive

Is Troponin Enough?

July 17, 2018

You are the emergency doc working in a rural ED. It is the Saturday night at 23:25 and you have three patients with chest pain.

A 13-year-old with testicular pain

July 18, 2018

In case you didn’t encounter a patient with testicular pain today! iEM Education Project Team uploads many clinical picture and videos to the Flickr and

Listen chapters on the go!

July 18, 2018

Uploading Audio Chapters 68% 28 chapters are ready to listen and download, 100 to go…

Acute Heart Failure (AHF)

July 19, 2018

by Walid Hammad – USA Case Presentation An ambulance crew rushes into your emergency department (ED) with a 56-year-old man. He is severely short of

I…can’t…breathe!

July 19, 2018

A New Chapter Is Just Uploaded To The Website! An ambulance crew rushes into your emergency department with a 56-year-old man. He is severely short

A kid with wrist pain!

July 20, 2018

In case you didn’t encounter a kid with wrist pain today! Pediatric fractures affecting growth plate are classified with Salter-Harris classification. It is from I

Core EM Clerkship Topics

July 16, 2018July 16, 2018 ~ iEM Education Project Team ~ Leave a comment

Core EM clerkship topics recommended by SAEM are ready for students. Feel free to read or listen. And, do not forget to share with your colleagues and students. Sharing is caring!

Shock

by Maryam AlBadwawi Introduction Shock, in simple terms, is a reduced circulatory blood flow state within the body. The inadequate circulation deprives the tissues of its

Chest Pain

by Asaad S Shujaa Introduction Chest pain is one of the most common symptoms presented in the emergency department (ED), and it is worrisome because

Gastrointestinal Bleeding

by Moira Carrol, Gurpreet Mudan, and Suzanne Bentley Case Presentation A 61-year-old man with a history of liver cirrhosis secondary to chronic EtOH abuse presents to

Headache

by Matevz Privsek and Gregor Prosen Introduction Headache is a subjective feeling of pain, crushing, squeezing or stabbing anywhere in the head. They are typically

Respiratory Distress

by Ebru Unal Akoglu Case Presentation A 40-year-old female with a history of diabetes mellitus presents with a complaint of 6 days cough and muscle

Multiple Trauma

by Pia Jerot and Gregor Prosen Case Presentation A 28-year old male was a restrained driver in a head-on motor vehicle collision. He was entrapped and

Poisonings

by Harajeshwar Kohli and Ziad Kazzi Case An 18-year-old, previously healthy female, presents to the Emergency Department with nausea, vomiting, and tremors. She states 45

Cardiac Arrest

by Abdel Noureldin and Falak Sayed Quick link to Spanish Version Introduction A 23-year-old female was brought into the emergency department. Her frantic family members

Altered Mental Status

by Murat Cetin, Begum Oktem, Mustafa Emin Canakci Case Presentation An 80-year-old female presents to the emergency department with a tendency to sleep (altered mental

Abdominal Pain

by Shaza Karrar Case Presentation A 39-year-old female presented to the emergency department (ED) complaining of right-lower-quadrant (RLQ) pain; pain duration was for 1-day, associated

Happy week with tons of education!

July 9, 2018July 9, 2018 ~ iEM Education Project Team ~ Leave a comment

Take EM Clerkship Seriously!

July 2, 2018July 2, 2018 ~ iEM Education Project Team ~ Leave a comment

This chapter describes how and why important the emergency medicine clerkship is. Although it aims to reach medical student/interns, there are many lessons to learn for us, educators.

The Importance of The Emergency Medicine Clerkship

by Linda Katirji, Farhad Aziz, Rob Rogers, USA

The Emergency Medicine (EM) clerkship typically takes place during the fourth year of medical school. However, some programs may have an optional elective during the third year. Whether or not you plan to specialize in Emergency Medicine, the rotation is an important aspect of your medical education. The emergency room is a unique learning environment which is different than any other setting in the hospital. It provides clinical opportunities that are largely unavailable in other clerkships and rotations. During residency, many specialties will also spend a significant amount of time in the Emergency Department (ED). This may be within a structured EM rotation, or while admitting or seeing patients for a certain medical or surgical service. Therefore, it is important to gain an understanding of the flow of the ED as well as the particular thought process that must be employed with emergency department patients…