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James R. Jacobs, M.D., Ph.D.Executive Director, Vaden Health Center
Associate Vice Provost for Student Affairs
Associate Professor of Psychiatry and Behavioral Sciences and Emergency Medicine
Stanford University
ACHA Annual Meeting | Austin | 2 June 2017
Skin Conditions that Sometimes Require an ER
Disclosures
CONFLICT OF INTEREST
I have NO actual or potential conflict of interest in relation to this
educational activity or presentation.
There is no financial support for this presentation from any entity.
OFF-LABEL USE OF MEDICATIONS
I do not anticipate discussing the unapproved use of commercial
products during this presentation.
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
3
Learning Objectives Content
DESCRIBE DANGEROUS BACTERIAL SKIN
CONDITIONS
DESCRIBE DANGEROUS VIRAL SKIN
CONDITIONS
DESCRIBE DANGEROUS IMMUNOLOGICAL
AND INFLAMMATORY SKIN CONDITIONS
Meningococcemia, necrotizing
fasciitis, RMSF, scalded skin and
toxic shock syndromes, complicated
cellulitis, complicated cutaneous
abscess, anthrax
Multidermatomal zoster, Herpes
zoster ophthalmicus, varicella with
systemic symptoms, smallpox
DRESS syndrome, Stevens-Johnson
syndrome/toxic epidermal necrolysis,
anaphylaxis
Sick vs. Not Sick; Clinic vs. ER
Oral medication vs. IV medication
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Mid-presentation questions for pharmacy credit
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
• Ceftriaxone is considered to be a broad spectrum
antibiotic.
• True or false
• Intravenous administration of ceftriaxone is more effective
than intramuscular administration.
• True or false
• Ceftriaxone 2 g should never be administered prior to 911
transport to the ER for a case of suspected
meningococcemia.
• True or false
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Necrotizing fasciitis
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Necrotizing fasciitis
• Rare but limb- and life-threatening soft-tissue infection
• Characterized by rapidly spreading inflammation and subsequent
necrosis of the fascial planes and surrounding tissue
• More accurately named necrotizing soft tissue infection
• Mortality increases with depth of infection
• 3 Proposed Types
• Polymicrobial (most common)
• Monomicrobial
• Vibrio vulnificus (worst)
• The infection typically follows a trauma
• Ranging from major surgery to injection sites to minor abrasion or
insect bite
• Often unnoticed
• Treatment is surgical debridement
• Time-to-debridement is most important factor affecting mortality
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Necrotizing fasciitis
• Usually presents with the classic triad of local pain, swelling, and erythema
• Classic signs and symptoms
• Blisters and bullae form and drain
• Initially serosanguineousfollowed by hemorrhagic fluid
• Skin shows violaceous discoloration before turning frankly necrotic and sloughing
• Crepitus may be present
• Disproportionate pain is replaced by analgesia
• Tachycardia (>100 beats/min) and fever are the most common vital sign abnormalities, followed by hypotension (SAP<100 mmHg) and tachypnea (>20/min)
• Infection can spread as fast as 1 inch per hour with little change in overlying skin
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Necrotizing fasciitis
• Consider the possibility
• Tenderness beyond the margins of the visible problem
• Pain out of proportion to the visible problem
• Crepitus
• Rapid worsening
• Be especially wary if this is the 2nd or 3rd visit for the same acute,
initially minor skin problem
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Multidermatomal Herpes Zoster
Reactivation of varicella zoster virus
involving the dermatomes supplied by
the first branch (V1) of the trigeminal
nerve ganglion with ocular involvement
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Herpes zoster ophthalmicus
Reactivation of varicella zoster virus
involving the dermatomes supplied by
the first branch (V1) of the trigeminal
nerve ganglion with ocular involvement
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Herpes zoster ophthalmicus
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Herpes zoster ophthalmicus
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
4 cm
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Smallpox Varicella
Smallpox
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Meningococcemia
Most patients infected with N meningitidis present with acute illness
Early symptoms reported by patients with meningococcal meningitis
and/or meningococcemia are often nonspecific (e.gg, fever, headache,
malaise) and challenge the early diagnosis of a meningococcal infection
The classic triad of fever, meningismus, and altered mental status is
observed in only one-third of patients with meningococcal meningitis at
presentation
Characteristic petechial rash is a more specific finding, but it is observed
in only 45% to 65% of cases at presentation
Although up to one-quarter of patients with meningococcal meningitis
have focal neurologic deficits (eg, aphasia, cranial neuropathies), these
are late findings, and their absence cannot be used to rule out a diagnosis
of meningitis
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Meningococcemia
• Cutaneous findings in meningococcemia are not consistently presents
• In one series of adult patients, 50% had no cutaneous findings
• When present, skin findings are not specific
• Morbilliform eruptions, papules, and vesicles may occur early in the
disease, then purpura subsequently develops
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Meningococcemia
• Palpable purpura is a raised, non-blanchableerythema and signifies extravasation of red cells outside of blood vessels
• Vasculitis, regardless of its cause, most commonly presents as palpable purpura
• This distinctive petechial rash occurs as a result of endotoxin-induced damage to endothelial cells and attendant thrombosis, necrosis, and eventually dermal hemorrhage
• In meningococcemia, purura may progress to purpura fulminans, disseminated intravascular coagulation, and thromboses
• Although the petechial rash is a characteristic finding in patients with severe disease, a similar rash may also be observed in other febrile conditions such as Rocky Mountain spotted fever, severe DIC (due to other causes), thrombotic thrombocytopenic purpura, Henoch-Schonlein purpura, and other vasculitides
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
Mid-presentation questions for pharmacy credit
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER
• Ceftriaxone is considered to be a broad spectrum
antibiotic.
• True or false
• Intravenous administration of ceftriaxone is more effective
than intramuscular administration.
• True or false
• Ceftriaxone 2 g should never be administered prior to 911
transport to the ER for a case of suspected
meningococcemia.
• True or false
SKIN CONDITIONS THAT SOMETIMES REQUIRE AN ER