Drug Rashes

• Unsurprisingly key in diagnosis is a good history.

• Most commonly caused by antibiotics.

• 90% are morbilliform: widespread erythematous macules or papules

• Common timeframe is 1-2 weeks after starting drug (however some can take up to three weeks).

Rash Presenting Symptoms Onset After Drug Causes Treatment Erythema Multiforme Target like lesions symmetric on trunk and extremities (generally distributed acrally) Mucous membrane involvement in multiforme major.

3-14 days HSV primarily; also NSAIDS, sulfa drugs, antibiotics, anti-epileptics. Stop offending agent. Drug Rash with Eosinophilia and Systemic Symptoms Syndrome (DRESS)

Fever and rash. Must be organ involvement: hapatic (60-80%), renal, lung. 2-8 weeks Anticonvulsants and allopurinol, additionally sulfa medications, antibiotics, CCB, NSAIDs, and anti-retrovirals (LFTs and BMP should be trended). Topical corticosteroids for rash. Systemic corticosteroids (for interstitial lung disease or nephritis); supportive care/withdrawl of causative agent for organ involvement

Stevens-Johnsons

Sydrome

Blisters with mucous membrane involvement

SJS involves less than 10% of the skin surface.

+Nikolsy

4-28 days Allopurinol, sulfa drugs, anti-epileptics, nevirapine and oxicam NSAIDs Range from observation to ICU level care (consider burn unit for approaching >30% BSA)

IV-IG and systemic corticosteroids are controversial.

Stop drug. Supportive.

Toxic Epidermal Necrolysis Similar to above, however involves >30% of skin.

4-28 days Same as above, however >80% are due to drug. Same as above. Burn Unit/ ICU setting. Serum Sickness-Like Reaction* Rash: urticarial polycyclic wheals on trunk, limbs, face. Fever. Arthralgias in >2/3 patients. 1-2 weeks Penicillin, amoxicillin, cefaclor, bactrim Stop drug. Supportive

Note: True sereum sickness-- protein antigen from a nonhuman species (antitoxin for snake bites, rabies). 

Intranasal Analgesia and Anxiolysis

Today we will be discussing IN anxiolysis and analgesia, especially useful in our pediatric population.  An appendix with a BAN administration outline is also attached. Indications

Perfect for kids coming in with acute trauma (laceration, need for x-rays, etc) or patients undergoing procedures such as I&D of an abscess.

May be used prior to obtaining x-rays for pain control in children not necessarily needing a line for reduction (or even in those needing a line as this may be a faster way to reduce pain, and may help provider in obtaining IV line).

Routine Medications – Analgesia/Anxiolysis Dose

• Analgesia: Fentanyl (1-1.5mcg/kg), Ketamine (0.5mg/kg)

• Anxiolysis: Midazolam (0.2mg/kg)

Other IN Medications: Midazolam, Precedex (dexmedotomidine), flumazenil, naloxone

Pearls of Administration

Have patients blow their nose first if possible.

Try to limit dose to 0.3mL per nostril (certainly no more than 1 mL per nostril), using concentrated solutions. 

Divide larger volumes over two nostrils.

May deliver in aliquots 10-15 minutes apart if larger.

Remember, it’s a good idea to put patients on a pulse ox prior to administration.

Account for “dead space” of atomizer (~1mL).  

APPENDIX

BAN Dosing

Remember, there is also the BAN (breath actuated nebulizer) for medication administration which is a an alternative to intranasal medications when tolerated.  Only use BAN in Breath Actuated Mode in ED.

Here is the dosing for BAN:

• Fentanyl:

  • Adults: 4mcg/kg dose titrated q 10 min up to three doses

  • Pediatrics: 2-4 mcg/kg titrated q 10 min up to three doses

• Morphine:

  • Adults: 10-20 mg titrate q 10-15 min up to three doses

  • Pediatrics: 0.2 mg/kg q15 min up to three doses

Pulmonary Contusion

History:

• Symptoms include SOB and chest pain.

  • Remember this may manifest as back pain depending on mechanism.

  • Look for in high impact injuries to chest (MVC, fall, pedestrian struck, trampled by livestock, etc)

  • MOA being compression-decompression.

Exam:

• Flail chest or crackles (however unlikely unable to auscultate in ED).

• Observe for crepitus for possible pneumothorax.

• Seatbelt sign.

Diagnosis:

• CXR or CT chest

• Extent of injury not apparent on CXR for 24-48 hours

• Areas of lung opacification within 6 hours diagnostic of pulmonary contusion.

• There are NEXUS chest guidelines (yes, chest!) for patients>14 to omit any imaging in chest trauma (see appendix below) - 98.8% sensitive.

• Look for homogenous focal or diffuse opacity that may cross typical anatomical landmarks (i.e. lobes).

Treatment:

• Primarily supportive. Watch for delayed presentation!

• Consider Bipap; pain control with intercostal block or epidural inpatient. Avoid unnecessary fluids.

• Up to 40-60% will require mechanical ventilation. Also may be necessary to sedate for pain control.

• Place good lung in dependent position to improve V/Q mismatch 50% go on to develop ARDS (blood in alveoli activates inflammatory cascade).

• If not improving - ECMO (V-V) is a possibility.

Bottom line:

• Monitor patients suspicious for pulmonary contusion - if they have signs of CXR there is a good chance they may need more invasive support (e.g. intubation).

• Have low suspicion for concurrent injuries including mediastinal and vascular injuries, diaphragmatic rupture, and cardiac contusion.

• Be aware of patient fluid status and try not to overload patient.

Keywords:  Pulmonary Contusion NEXUS Chest Radiography Chest Trauma