Rosen & Barkin's 5-Minute Emergency Medicine Consult (654 page)

• Skin lesions themselves require no specific ED treatment
  
• Treat complications of visceral involvement by metastatic melanoma, SCC or locally invasive BCC.
  

FOLLOW-UP

• Admission typically only occurs due to complications associated with visceral involvement or invasive spread
  
• Admission is rarely required because of the dermatologic lesions themselves
  

Patients are generally discharged with instructions on obtaining biopsy and/or further evaluation

Discharged patients should be advised to consult a dermatologist or primary care physician experienced with skin biopsy.

• Biopsy is required for diagnosis of skin cancer
  
• Urgent follow-up with dermatologist or primary care physician is advised
  
• Ensure adequate documentation of conversation with patient regarding urgency of follow-up
  
• Patients with nonmelanoma skin cancer have a 30–50% chance of developing additional skin cancer within 5 yr
  

• Advise patient to obtain urgent follow-up for any suspicious lesion
  
• 1 in 6 people will have skin cancer during their lifetime
  
• Protection from UVA and UVB rays is key to preventing skin cancer
  

• Arora A, Attwod J. Common skin cancers and their precursors.
  Surg Clin North Am
  . 2009;89:703–712.
  
• Califano J, Nance M. Malignant melanoma.
  Facial Plast Surg Clin North Am
  . 2009;17:337–348.
  
• Firnhaber JM. Diagnosis and treatment of basal cell and squamous cell carcinoma.
  Am Fam Physician
  . 2012;86:161–168.
  
• Lee DA, Miller SJ. Nonmelanoma skin cancer.
  Facial Plast Surg Clin North Am
  . 2009;17:309–324.
  
• Ricotti C, Bouzari N, Agadi A, et al. Malignant skin neoplasms.
  Med Clin North Am
  . 2009;93:1241–1264.
  

CODES

• 173.90 Unspecified malignant neoplasm of skin, site unspecified
  
• 173.91 Basal cell carcinoma of skin, site unspecified
  
• 173.92 Squamous cell carcinoma of skin, site unspecified
  

BASICS

• Disorder characterized by cessation of breathing during sleep:
  
  • Defined as apneic episodes >10 sec with brief EEG arousals or >3% oxygenation desaturation
    
• Risk factors:
  
  • Obesity
    
  • Male
    
  • >40 yr of age
    
  • Upper airway anomalies
    
  • Myxedema (hypothyroidism)
    
  • Alcohol/sedative abuse
    
  • Smoking
    
• Associated illness:
  
  • Various dysrhythmias, particularly atrial fibrillation and bradyarrhythmia
    
  • Right and left heart failure
    
  • MI
    
  • Stroke
    
  • Motor vehicle accidents
    
  • Hypertension poorly controlled by medical therapies
    

• Affects about 9% of middle-aged men and 4% of middle-aged women
  
• 80% of moderate or severe cases undiagnosed in middle-aged adults
  

3 classifications of sleep apnea:

• Obstructive (84%) is due to upper airway closure despite intact respiratory drive:
  
  • Also known as Pickwickian syndrome
    
  • Pharyngeal airway is narrowed
    
• Central (0.4%) is due to lack of respiratory effort despite patent upper airway.
  
• Complex (15%) is due to a combination of obstructive and central sleep apnea.
  

DIAGNOSIS

• Excessive daytime sleepiness
  
• Snoring
  
• Irritability
  

• Significant other apnea report
  
• Difficulty sleeping
  
• Decreased attention/concentration
  
• Depression
  
• Decreased libido/impotence
  

• Hypertension, hypoxemia
  
• Obesity
  
• Craniofacial anomalies
  
• Macroglossia
  
• Enlarged tonsils
  
• Elevated jugular veins (secondary to pulmonary hypertension)
  
• Large neck circumference
  

• Pulse oximetry
  
• ECG
  
• Chest radiograph
  

ABG is the best test to demonstrate hypercarbia and hypoxemia.

• Consider lateral neck soft tissue radiograph to rule out other etiologies of upper airway obstruction.
  
• Chest radiograph to assess other etiologies of hypoxemia
  
• Chest CT rarely indicated
  

Polysomnogram (PSG) is required for diagnosis:

• >5 apneic episodes per hour
  
• Not a consideration for ED management
  

• Asthma
  
• Cheyne–Stokes breathing
  
• COPD
  
• Diaphragmatic paralysis
  
• High altitude–induced periodic breathing
  
• Hypothyroidism
  
• Left heart failure
  
• Narcolepsy
  
• Obesity hyperventilation syndrome
  
• Primary pulmonary hypertension
  

TREATMENT

Caution not to overventilate patient with chronic CO retention

Chin lift/jaw thrust maneuver, oxygen as needed, oral or nasal airway devices

• Proper technique is required for airway management:
  
  • Supplemental oxygen as needed
    
  • Bag-valve-mask ventilation may be difficult:
    
    • Consider the use of nasal and oral airways
      
    • 2-person technique to ensure a good seal
      
• Continuous positive airway pressure (CPAP) is the standard of treatment:
  
  • Acts as a pneumatic splint by maintaining upper airway patency
    
  • BiPAP is an alternative for patients requiring high pressures or with comorbid breathing disorders.
    
  • Long-term CPAP therapy decreases BP, insulin resistance, metabolic syndrome, and risk of cardiovascular disease.
    

• Insufficient evidence to recommend any medication for treatment
  
• See Airway Management for details on induction agents and neuromuscular blockade.
  
• Wakefulness-promoting agents (modafinil and armodafinil) are approved as an adjunct to CPAP patients with excessive sleepiness.
  

• Gold Standard
  
  • CPAP compliance and weight loss strongly recommended by the American College of Physicians
    
• Surgical considerations:
  
  • Most intend to reduce or bypass the excessive pharyngeal/airway resistance that occurs during sleep.
    
  • Efficacy is unpredictable; no good randomized trials
    
  • Not a consideration for ED management
    
• Dental devices:
  
  • Currently recommended by the American Academy of Sleep Medicine (AASM)
    
  • Available appliances include tongue repositioning and mandibular devices or soft-palate lifters.