Consider toxic shock

Consider Kawasaki

Consider staph scalded skin

Consider toxic epidermal

necrolysis

Consider Stevens-Johnson

Treat for

meningococcemia

Figure 96-5. Life-threatening dermatoses diag nostic algorithm.

CHAPTER 96

These patients do not require hospital admission.

Patients with Stevens-Johnson syndrome will require IV

fluids and debridement of large bullae. IV antibiotics

should be administered for any coexisting infection.

Patients should be admitted to a burn unit or ICU setting for wound care. TEN patients require care similar

to that for SJS patients; however, they will require burn

unit care because of the large amount of desquamation.

Patients with pemphigus vulgaris should be treated with

IV corticosteroids and fluid resuscitation. They should

be admitted to the hospital.

..... Hemorrhagic Lesions

Patients with DGI require IV ceftriaxone. Admission is

required for systemically ill patients or those with

involvement of weight-bearing joints. Patients with

meningococcemia can deteriorate quickly over several

hours, leading to hypotension, shock, renal failure, acute

respiratory distress syndrome, and disseminated

intravascular coagulation. Treatment consists of broadspectrum IV antibiotics (ceftriaxone and vancomycin) and

ICU admission.

SUGGESTED READING

Rosenstein NE, Perkins BA, Stephens DS, Popovic T, Hughes J.

Medical progress: Meningococcal disease. N Engl l Med.

200 1;344: 1378-1 388.

Thomas J, Perron A, Brady W. Serious generalized skin disorders.

In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK,

Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 201 1,

pp. 1614--1624.

Weber DJ, Cohen MS, Morrell DS, Rutala WA. The acutely ill

patient with fever and rash. In: Mandell GL, Bennett JE, Dolin

R, eds. Mandell, Douglas, and Bennett's Principles and Practice

of Infectious Disease. Philadelphia, PA: Elsevier Churchill

Livingstone, 2009, pp. 791-807.

Al lergic Reactions

Lisa R. Pa livos, MD

Key Points

• Epinephrine is the first-line medication for the treatment of anaphylaxis. Second-line treatment consists of

antih istami nes and corticosteroids.

• Urticaria may be the first sign of what might prog ress to

angioedema or anaphylaxis.

INTRODUCTION

An allergic reaction is the body's way of responding to

foreign substances that come in contact with the skin, nose,

eyes, respiratory tract or gastrointestinal tract. Examples of

allergens are dust, pollen, plants, medications, foods, latex,

and insect bites. Anything can be an allergen. Allergic

reactions can range from mild local urticarial eruptions

to severe and life-threatening airway obstruction, respiratory failure, and circulatory collapse. Urticaria, or "hives;'

is an immunoglobulin E (IgE)-mediated hypersensitivity

reaction to an allergen resulting in red, raised wheals that

itch and sting. Circulating antibodies bind the allergen and

IgE receptors on mast cells. In response, mast cells release

inflammatory substances (histamine, bradykinin), which

results in increased vascular permeability. Urticaria is one

of the most common skin lesions seen in the emergency

department (ED) in both young and older patients. About

20% of the population experiences at least 1 attack of

urticaria in their lifetime.

Angioedema is nonpitting edema of the deeper layers of

the skin owing to a loss of vascular integrity caused by inflammatory mediators. It is not pruritic but can cause burning,

numbness, or pain, generally in the face or neck. Approximately 94% of the cases of angioedema presenting to

the ED are drug-induced. Most drug-induced angioedema

occurs in patients taking angiotensin-converting enzyme

• For patients with respiratory symptoms or throat swelling, perform a rapid assessment of the airway and

intubate early.

• Attempt to determine and then discontinue the inciting

agent.

(ACE) inhibitors. About 0. 1-0.2% of the patients treated

with ACE inhibitors will develop angioedema. There are

2 main types of angioedema based on the underlying

mechanism. Mast cell angioedema is mediated by IgE,

similar to urticaria. Bradykinin, an inflammatory mediator,

is causal in both hereditary and ACE inhibitor-induced

angioedema, although the mechanism for the bradykinin

increase differs.

Anaphylaxis is a severe systemic allergic reaction that can

present rapidly with hypotension, bronchospasm, and

laryngeal edema. About 500-1,000 persons in the United

States die every year as a result of anaphylaxis. Beta-lactam

antibiotics and Hymenoptera stings constitute the most

common causes of anaphylaxis. Anaphylaxis is 1gB-mediated

and results from release of histamine, leukotrienes, and

prostaglandins from inflammatory cells. The result is a systemic increase in vascular permeability, vasodilation, and

smooth muscle contraction.

CLINICAL PRESENTATION

� History

Patients with urticaria present with transient, pruritic, wellcircumscribed lesions that are erythematous, nonpitting

plaques (wheals) surrounded by an erythematous ring (flare)

(Figure 97-1 ). Patients with angioedema present with swelling

423

CHAPTER 97

.A Figure 97-1. Urticaria. Reprinted with permission

from Ka ne KS, Bissonette J, Baden HP, et al. Color Atlas

Er Synopsis of Pediatric Dermatology. New York:

McGraw-Hill, 2002.

of the face, lips, tongue, eyelids, distal extremities, or genitalia

The swelling is nonpitting and may occur with urticaria. ACE

inhibitor-induced angioedema has a predilection for the face

(Figure 97-2). Patients with anaphylaxis present with a

sensation of impending doom or "lump in the throat"

followed by shortness of breath, chest pain, hypotension,

nausea, vomiting, or diarrhea. More than 90% of patients

have urticaria or angioedema. Most patients present with

signs and symptoms within seconds of exposure to an

allergen; however, symptoms may be delayed up to a few

hours after exposure.

.A Figure 97-2. Angioedema of the lips. Reproduced

with permission from Sarah M. Granlund.

If the patient is stable, try to identify the inciting factors.

Ask about history of allergies, medications, exposures,

contacts, underlying illness, diet, and family history of allergic reactions.

� Physical Examination

Initial evaluation of the patient should focus on airway,

breathing, and circulation (ABCs). Airway obstruction is

evidenced by swelling of the lips, tongue, or uvula. The

patient may have hoarseness, stridor, wheezing, or respiratory

distress. The patient may exhibit erythema, urticaria, pruritis, or angioedema of the face, neck, or extremities. In

patients with ACE inhibitor angioedema, the face is involved

in 86% of cases.

Once a patient is hemodynamically stable, a more

detailed physical exam should be performed. Examine the

skin while the patient is undressed and describe the rash.

Include the type (macular, papular, vesicular), size, shape,

number, and color of the rash. Remove the allergen if it can

be identified. For example, remove stinging remnants from

insect bites .

DIAGNOSTIC STUDIES

Diagnosis of urticaria, angioedema, and anaphylaxis is

based on clinical symptoms, and no specific laboratory or

imaging tests are necessary.

MEDICAL DECISION MAKING

History and physical examination should be sufficient to

arrive at the diagnosis of acute allergic reactions, especially

if there is clear history of an exposure, such as a bee sting.

Diagnosis is not always obvious because anaphylaxis symptoms may mimic other presentations such as myocardial

infarction, pulmonary embolism, syncope, status asthmaticus, or sepsis. Urticaria may be confused with a viral rash,

erythema multiforme, or a vasculitis. Infection (cellulitis),

contact dermatitis, and renal or liver disease may mimic

angioedema (Figure 97-3).

TREATMENT

Anaphylaxis with airway compromise and hypotension is a

true medical emergency and must be rapidly assessed and

treated. The most important step in treatment is the rapid

administration of epinephrine.

Initial stabilization consists of ABCs, cardiac monitoring,

oxygen, and intravenous (N) fluids. Further treatment

depends on the severity and extent of the reaction. When the

airway is threatened, early intubation is lifesaving.

Epinephrine is indicated in patients with angioedema when

the airway is compromised or in patients with bronchoconstriction or hypotension from anaphylaxis. If the patient is

normotensive and without signs of cardiovascular collapse,

administer 0.3--D.S mg intramuscularly (IM) (0.3--D.S mL of

1:1,000 [1 mg/1 mL) epinephrine every 5-10 minutes until

ALLERGIC REACTIONS

Antihistamines,

steroid, remove

allergen

• Figure 97-3. Allergic reactions diagnostic algorithm.

a positive response. IM dosing provides better blood epinephrine levels than subcutaneous administration.

Injections into the thigh are more effective than injections

into the deltoid area. If the patient does not respond or is

hypotensive with signs of cardiovascular compromise, give

epinephrine 0.1 mg IV slowly over 5 minutes (1 mL of

1: 1 0,000 solution [ 1 mg/1 0 mL] ). If the patient is refractory

to the bolus, then an epinephrine infusion should be started.

Second-line treatments include corticosteroids and antihistamines. H1 blockers (diphenhydramine) should be

administered by mouth (PO) or IM for mild reactions and

IV for more severe reactions. An H2 blocker in combination

with H1 blocker should be administered to patients with

severe urticaria, angioedema, or anaphylaxis. Choices

include famotidine 20 mg IV, ranitidine 50 mg IV; or cimetidine 300 mg N. Corticosteroids should be administered for

all moderate to severe reactions (prednisone 4�0 mg PO

or methylprednisolone 125 mg IV). For treatment of bronchospasm, add an albuterol nebulizer, ipratropium bromide,

and magnesium sulfate.

Patients with hereditary and ACE inhibitor-induced

angioedema are usually refractory to treatment with

epinephrine, antihistamines, and corticosteroids. However,

it is difficult to distinguish these from angioedema due to

an IgE-mediated reaction, which respond to these therapies.

In the presence of an acutely ill patient, treatment of a

presumed hypersensitivity reaction is necessary while

considering other etiologies and treatments. None of the

additional therapies work immediately, thus prophylactic

intubation or cricothyrotomy should be performed when

edema is progressive and there is evidence of airway

compromise.

Discontinuation of ACE inhibitors leads to resolution

within 24-48 hours. Fresh-frozen plasma or purified C1

inhibitor concentrate may be administered for suspected

bradykinin mediated causes; however, improvement does

not occur for 2-4 hours. Both agents replace the enzyme,

kininase II, which breaks down excess bradykinin.

DISPOSITION

.... Admission

Patients with systemic symptoms or potential airway

compromise that does not resolve must be hospitalized in

an intensive care setting .

.... Discharge

Patients with resolution of symptoms may be discharged

after several hours of ED observation. Refer the patient to

an allergist or immunologist. Prescribe antihistamines

and steroids for 3-5 days, and if the reaction was severe,

prescribe an epinephrine autoinjector (EpiPen). Patients

with known triggers should be advised about strict

avoidance of those triggers. Advise patients about personal identification such as an allergy alert tag. Patients

taking ACE inhibitors should be instructed to discontinue the medication and also avoid angiotensin receptor

blockers.

SUGGESTED READING

Bwmey EB. Anaphylaxis. In: Wiebe RA, Ahrens WR, Strange GR,

Schafermeyer RW, eds. Pediatric Emergency Medicine. 3rd ed.

New York, NY: McGraw-Hill, 2009:589-59 1.

Rowe BH, Gaeta T, Gaeta TJ. Anaphylaxis, acute allergic reactions,

and angioedema. In: Tintinalli JE, Stapczynski JS, Ma OJ,

Cline DM, Cydulka, RK, Meckler GD. Tintinalli's Emergency

Medicine: A Comprehensive Study Guide. 7th ed. New York, NY:

McGraw-Hill, 201 1:177-182.

Simons, FE. Anaphylaxis. / Allerg Clin Immunol. 2010; 125(suppl 2):

S161-5181.

App roach to the

Psychiatric Patient

Leslie S. Zun, MD

Key Points

• New-onset psychiatric ill ness requires a comprehensive

emergency department work-up. Consider a medical

etiology.

• Prior psychiatric ill ness with similar presentation does

not require an extensive work-up.

INTRODUCTION

Psychiatric illness is a common presentation to emergency

departments (EDs). The number of psychiatric patients

presenting to EDs has increased both in total number and

in percentage of total ED visits, from 4.9% to 6.3% from

1992-200 1. The main ED psychiatric diagnoses are substance-use disorders (22%), mood disorders (17%), and

anxiety-related disorders ( 16%).

Patients with psychiatric illness may have various

presentations depending on their underlying psychiatric

diagnosis as well as their concurrent medical condition.

Psychiatric patients may present with depressed affect, psychosis, agitation, suicidal or homicidal ideation, catatonia,

delusions, or dementia.

Like other conditions presenting to the ED, the

emergency physician must determine whether the patient

has a life-threatening condition. The life-threatening

conditions include suicidal or homicidal plans and medical

condition masquerading as psychiatric illness ( Table 98-1).

Frequently identified medical causes of abnormal behavior

include hypoglycemia, hypoxia, seizures, head trauma, and

thyroid abnormalities. Patients should also be assessed for

the presence of delirium or dementia, as both have

potentially treatable causes. The primary role of the ED

physician is to determine whether the psychiatric

presentation is due to a medical or psychiatric etiology.

• Agitated patients need immediate treatment in the

emergency department.

• Patients with suicidal and homicidal plans or i nabil ity to

care for themselves need psychiatric admission.

Table 98-1. Medical conditions that masquerade

as psychiatric disease.

Alcohol intoxication or withdrawal

Anticholinergic poisoning

Drug intoxication or withdrawal

Electrolyte abnormal ity

Head injury

Hepatic failure

Hyperthyroidism

Hypoglycemia

Meningitis and encephalitis

Renal failure

Seizure

Stroke

Wernicke encephalopathy

This determination is often referred to as the medical

clearance process. The secondary role of the ED physician

is to evaluate the patient's coexisting medical conditions

because many of these psychiatric patients have a high

incidence of medical illnesses that have been neglected.

426

APPROACH TO THE PSYCHIATRIC PATIENT

Some psychiatric patients present to the ED with acute

agitation. These patients, like others in the ED, are acutely

ill and need to be stabilized before definitive evaluation can

be completed. Once the agitation has been reduced, the

clinician must determine the cause of the agitation and the

need for a psychiatric versus medical admission.

CLINICAL PRESENTATION

� History

A detailed history, including prior psychiatric history, is

the most important step to determine whether the patient's

presentation is due to a medical or psychiatric problem. It

is important to determine whether the patient's current

presentation is the same or similar to previous psychiatric

presentations. Some psychiatric patients can provide a

history of their condition, whereas others may require

collateral information. History from family, bystanders,

paramedics, police officers or medical records can provide

valuable information. Medical and psychiatric history,

medications, medication compliance, substance use, and

recent stressors may provide insight into the patient's

presentation.

Multiple factors cause a psychiatric patient to

decompensate and present to the ED, including

concomitant substance use and withdrawal, noncompliance

with psychotropic medications, change in social situation,

and environmental stressors. It is valuable to determine

these factors to better address the patients' needs.

� Physical Examination

The physical examination can provide important clues into

the etiology of the patient's presentation. The "red flags"

indicating a possible medical etiology include age over

45 years, bowel or bladder incontinence, cognitive deficit,

abnormal vital signs, and abnormal or focal examination

(Table 98-2).

A psychiatric patient should have a thorough

examination in the ED. A head-to-toe examination with

focus on a neurologic and mental status examination is

essential. The neurologic examination should assess for

focal deficits by evaluating cranial nerves, sensation,

strength, reflexes, and coordination. Every patient requires

a mental status examination that should include

Table 98-2. Red flags of medical ill ness.

Age >45 years

Bowel or bladder incontinence

Focal neurologic examination

Cognitive deficit

Abnormal vital signs

Abnormal or focal physical examination

appearance, behavior and attitude, disorders of thought,

disorder of perception, mood and affect, insight and

judgment, sensorium, and intelligence. Patients also need

an evaluation of their cognitive functioning because many

times a deficit cannot be detected in a routine ED

examination. Specific tests of cognitive function include

the Mini-Mental State Examination, Clock Drawing Test,

and the Cognitive Capacity Screening Examination.

Patients with a psychiatric etiology for their symptoms

usually have normal vital signs, a nonfocal examination,

and a normal test of cognitive function, whereas patients

with medical etiologies may have abnormal vital signs, a

focal examination, or an abnormal cognitive deficit.

Patients with abnormal level of arousal and cognition may

have delirium, whereas patients with normal arousal, but

impaired cognition may have dementia.

DIAGNOSTIC STUDIES

� Laboratory

Clinical judgment should determine the need for lab

testing of patients presenting with psychiatric complaints.

Rather than using clinical judgment, some institutions

have a set of laboratory tests that are routinely performed

on all patients with behavioral complaints. Patients with a

first-time presentation of psychiatric illness or a change in

the presentation of their psychiatric symptoms should have

general laboratory studies (complete blood count [CBC] ,