The Washington Manual Internship Survival Guide by Thomas M. De Fer & Eric Knoche & Gina LaRossa & Heather Sateia

Author:Thomas M. De Fer & Eric Knoche & Gina LaRossa & Heather Sateia [De Fer, Thomas M.]
Language: eng
Format: mobi
Publisher: Wolters Kluwer Health
Published: 2013-03-13T00:00:00+00:00

• Transfer to burn unit/ICU.

• IV fluids, NG tube.

• Sterile protocol, antiseptic solution, and nonadherent dressings.

• Antibiotics only if high suspicion for sepsis.

• Consider systemic steroids and/or IVIG. Their use is decided on a case-by-case basis.

• Ophthalmology consult.

• OB/GYN consult for vaginal involvement; urology consult for urethral involvement.

• Clinical pearls: Hepatitis occurs in 10%. Most patients have anemia and lymphopenia. Neutropenia is associated with poor prognosis. Hypothermia is more indicative of sepsis than fever. Patients with HIV, systemic lupus, or a bone marrow transplant have a higher risk of developing TEN.

• Prognosis: TEN has a mortality rate of 30% to 40% and is most often secondary to sepsis, renal failure due to hypovolemic shock, or ARDS.

Toxic Shock Syndrome

• Emergency: call an ID consult immediately!

• Pertinent information: Age of patient, immunocompromised status, menstrual history, recent surgeries, diabetes, chronic cardiac or pulmonary disease.

• History: Painful erythematous skin eruption, sudden onset of high fever, nausea/vomiting, diarrhea, sore throat, confusion, headache, myalgias, and hypotension.

• Physical exam: Fever >102°F; erythematous rash initially appearing on trunk, spreading to arms and legs and involving palms and soles, progressing to diffuse erythema and edema. Involves the oral mucosa. In 10 to 12 days there is desquamation of the top layer of the epidermis (not full thickness as in TEN).

• Workup: Blood cultures, CBC (leukocytosis), CMP (hyponatremia, hypokalemia, hypocalcemia, elevated LFTs), ECG (arrhythmias), CXR. To consider: serologic testing for Rocky Mountain spotted fever, leptospirosis, measles, hepatitis B surface antigen, antinuclear antibody, VDRL, monospot antibody, rapid strep test, LP (should be normal).

• Diagnosis: Clinical (fever, typical rash, hypotension, multi-organ involvement).

• Treatment:

• Remove any infected foreign bodies.

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