Rosen & Barkin's 5-Minute Emergency Medicine Consult (721 page)

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Burns

CODES

• 695.14 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome
  
• 695.15 Toxic epidermal necrolysis
  

BASICS

• Toxic shock syndrome (TSS) is a severe, acute life-threatening illness
  
• Etiologic organisms:
  
  • Staphylococcus aureus
    , more common (TSS)
    
  • Group A streptococcus or GAS, less common (Streptococcal TSS or STSS)
    
• S. aureus
  produce structurally similar toxins:
  
  • Toxic shock syndrome toxin (TSST-1)
    
  • Enterotoxin B (SEB)
    
  • Enterotoxin C (SEC)
    
• GAS pyrogenic exotoxins:
  
  • Exotoxin A (SPEA)
    
  • Exotoxin B (SPEB)
    
• Exotoxins act as superantigens causing overwhelming immune response:
  
  • Massive cytokine production
    
  • Induce fever directly at the hypothalamus or indirectly via interleukin-1 (IL-1) and tumor necrosis factor (TNF) production
    
  • Enhance delayed hypersensitivity
    
  • Suppress neutrophil migration and immunoglobulin
    
  • Enhance host susceptibility to endotoxins
    
• Massive vasodilation occurs
  
  • Serum protein and fluid shifts leading to hypotension
    

• Initial cases described in young healthy menstruating females due to highly absorbent tampons
  
  • Changes made in tampon composition to decrease incidence
    
• Approximately one-half of reported TSS cases are nonmenstrual:
  
  • Surgical wounds
    
  • Postpartum wound infections
    
  • Mastitis
    
  • Septorhinoplasty
    
  • Sinusitis
    
  • Osteomyelitis
    
  • Arthritis
    
  • Burns
    
  • Nasal packing (nasal tampons)
    
  • Cutaneous and subcutaneous lesions
    
• Nonmenstrual cases predominantly due to SEB and SEC producing
  S. aureus
  
• 30–50% of healthy adults and children carry
  S. aureus
  in the nasal vestibule, vagina, rectum and/or on the skin
  
• GAS infections often begin within 24–72 hr at the site of minor trauma, often without a visible in skin
  
• Despite increased incidence of Methicillin-resistant
  S. aureus
  (MRSA) infections, a recent study reported MRSA only accounting for 7% of cases
  

DIAGNOSIS

• CDC case definition:
  
  • Fever >38.9°C (102°F)
    
  • Hypotension (systolic BP <90 mm Hg) or shock
    
  • Diffuse, blanching nonpruritic macular erythroderma rash
    
  • Subsequent desquamation 1–2 wk after the onset of illness (particularly involving palms and soles)
    
  • Multisystem involvement—
    at least 3
    of the following should be present:
    
    • GI: Profuse diarrhea or vomiting at onset of illness
      
    • Musculoskeletal: Severe myalgias or greater than a 2-fold increase in creatine phosphokinase (CPK)
      
    • Mucosal inflammation: Conjunctival, vaginal, or pharyngeal hyperemia
      
    • Renal: Increase in BUN or creatinine >2 times normal upper limit or sterile pyuria without evidence of infection
      
    • Hepatic: Total bilirubin or transaminases >2 times normal upper limit
      
    • Hematologic: Thrombocytopenia <100,000/mm
      ³
      
    • CNS: Disorientation, confusion, or hallucinations
      
  • Negative results on the following tests, if obtained: Throat, or CSF cultures, rise in titer to Rocky Mountain spotted fever (RMSF), leptospirosis, or rubeola
    

• CDC case definition:
  
  • Isolation of GAS from a normally sterile site
    
  • Hypotension
    
  • Plus 2 or more of the following:
    
    • Renal impairment (creatinine >2)
      
    • Coagulopathy
      
    • Liver involvement (>2 times the upper limit of normal for transaminases or bilirubin)
      
    • ARDS
      
    • Erythematous macular rash, may desquamate
      
    • Soft tissue necrosis
      

• Tachycardia frequently present
  
• Can rapidly progress to multisystem dysfunction (ARDS or DIC)
  
• STSS often presents with diffuse or localized pain—abrupt in onset and severe
  
• Pain precedes physical findings
  
• Nearly 80% of patients with STSS have clinical signs of soft tissue infection
  

• Clinical diagnosis using diagnostic criteria in the absence of other attributable illness
  
• Thorough history and physical exam
  

• CBC:
  
  • Leukocytosis or leukopenia, marked bandemia common
    
• Electrolytes, BUN, creatinine, glucose:
  
  • Elevated BUN and creatinine common
    
• Calcium, magnesium:
  
  • Hypocalcemia/hypomagnesemia often present
    
• Urinalysis:
  
  • Normal or sterile pyuria without evidence of infection
    
• CPK:
  
  • 2-fold increase
    
• Hepatic function:
  
  • Elevated total bilirubin, AST, ALT
    
• Prothrombin time (PT), partial thromboplastin time (PTT), platelets:
  
  • Thrombocytopenia <100,000 platelets/mm
    ³
    
• Culture the site of injury/infection if possible
  
• Blood, urine, throat, and CSF cultures as indicated:
  
  • The case definition does not require a positive blood culture for
    S. aureus
    , but does for
    Streptococcus
    organisms.
    
• Serology for RMSF, rubeola, and leptospirosis
  
• Hepatitis B surface antigen
  

• Chest x-ray – to rule out other sources of systemic illness
  
• Consider x-ray or CT scan if localized pain is concerning for abscess or necrotizing infection
  

• Staphylococcal scalded skin syndrome:
  
  • In children <5 yr of age
    
  • Initial macular rash followed by the formation of ill-defined bullae that can be rubbed off revealing a shiny, moist epidermis (positive Nikolsky sign)
    
• Scarlet fever:
  
  • Preceding streptococcal pharyngitis
    
  • Rash begins on the upper chest, neck, and back spreading to the remainder of the trunk, sparing the palms and soles
    
  • Hypotension absent
    
• Kawasaki disease:
  
  • Fever, conjunctival hyperemia, and erythema of the mucous membranes
    
  • Not associated with renal failure, hypotension, or thrombocytopenia
    
• Stevens–Johnson syndrome:
  
  • Severe multisystem involvement
    
  • Mucosal involvement of the mouth, conjunctivae, vagina, anus, and urethral meatus
    
• Leptospirosis:
  
  • Transmitted through contact with infected animals
    
  • Fever, headache, severe myalgias, and conjunctival suffusion
    
  • Truncal rash that only desquamates in children
    
• RMSF:
  
  • Rash is pink and macular, beginning on the wrists, palms, ankles, and soles spreading to the trunk and face
    
  • Petechiae appear after 4 days
    
• Meningococcemia:
  
  • Meningismus present
    
  • Rash is petechial
    

TREATMENT

• ABCs
  
• IV access
  
• IV fluids for hypotension
  

• Again, ABCs
  
• Aggressive management of circulatory shock
  
  • IV fluids
    
  • Pressors