POTD: Tinea Pedis (Athlete's Foot)

This PODT is inspired by a recent case I had in while working in Peds and is something we may encounter often in the summer. This is a perfect example of a fast track compliant that we may have not seen a lot of during COVID.

The patient was a young male in his 20s who works in construction and wears heavy boots and socks for about 8 hours of the day in the heat. He presented with 1 days of sloughing of the skin of both of his feet with discharge.

 Lets discuss Tinea Pedis (Athlete’s Foot):

 Tines pedis is a dermatophyte infection of the skin on the foot.

 Etiology and Risk Factors:

• Usually occurs in adults and adolescents and is rare prior to puberty

• Infection is acquired by means of direct contact with the causative organism

• Commonly seen in patients who have a history of walking barefoot in locker rooms or swimming pool facilities

• Also commonly seen in patients who wear occlusive footwear

Predisposing factors to consider

• Diabetes Mellitus

• Immunodeficiency, Systemic corticosteroid use, or use of immune suppressive agents

• Poor peripheral circulation or lymphoedema

• Excessive sweating (hyperhidrosis)

 Who would have know that there are different types of tinea pedis?

•  Types of Tinea Pedis:

  • Interdigital tinea pedis: Manifests as pruritic erosions or scales between the toes, most commonly in the third and fourth digital interspaces

    • More severe form of this is known as Ulcerative tinea pedis. This is generally associated with secondary bacterial infection

  • Hyperkeratotic (Moccasin-Type): Characterized by diffuse hyperkeratotic eruption involving the soles and medial and lateral surfaces of the feet.    

  • Vesiculobullous (inflammatory-type): Pruritic, sometimes painful, vesicular or bullous eruption. Medial foot often affected 

Management:

• Topical antifungal therapy is treatment of choice for most patients.

  1. Example of topical antifungal: Azoles, Allylamines, Butenafine, Ciclopirox, Tolnaftate, and Amorolfine. Recommended to apply once or twice a day for four weeks. (Refer to references for dosages and frequency)

  2. Beneficial and more effective for patients to use the suspension formulation of these medications

• Systemic antifungal agents are primarily reserved for patients who fail topical therapy

  1.   Terbinafine 250mg per day for 2 weeks in adults

     1. Most check LFTs prior to administration and patients need to follow up and have LFTs checked while receiving treatment

     2. Peds dosing:

        • 10 to 20kg: 62.5mg/day

        • 20 to 40kg: 125mg/day

        • Above 40kg: standard adult dosing

  • Itraconazole 200mg per day for two weeks

    •   Peds dosing:

      • 3 to 5 mg/kg per day

  • Fluconazole 150mg once weekly for two to six weeks

    • Peds dosing:

      •   6mg/kg once weekly

• ·Ulcerative Tinea Pedis;

  •   Always treatment with systemic antifungal agents in addition to topical antifungals

  • Make sure to add in addition to your antifungal an antibiotic such as Keflex

  • Outpatient podiatry follow up should be given to patients

• Prevention

  • Use of sock with wick-away material

  • Use of desiccating foot powders

  • Tx of hyperhidrosis if there is history of moist feet

  •   Tx of shoes with antifungal powder

  •   Avoidance of occlusive foot wear

 We diagnosed our patient with ulcerative tinea pedis. We started the patient on Terbinafine, Ciclopriox, and Keflex and arranged for podiatry follow up. Our patients case was unique in the fact that the patient had bilateral involvement normally this occurs unilateral.

 References :

·      https://www.uptodate.com/contents/dermatophyte-tinea-infections?search=tinea%20pedis&source=search_result&selectedTitle=1~103&usage_type=default&display_rank=1#H2658711829

·      https://www.uptodate.com/contents/image?csi=18b425c8-5b1f-4694-a039-5bc8aa27c160&source=contentShare&imageKey=PC%2F76148

·      https://wikem.org/wiki/Tinea_pedis

·      https://www.aafp.org/afp/2014/1115/p702.html

·      https://accessemergencymedicine.mhmedical.com/content.aspx?sectionid=109447903&bookid=1658

·      https://dermnetnz.org/topics/tinea-pedis/

EMS Protocol of the Week - General Cardiac Arrest Care (Non-Traumatic) (Adult)

The prehospital approach to general cardiac arrest care is a good introduction to the progression of responsibilities from one level of training to the next. We get a large number of OLMC calls from our own paramedics requesting physician input in arrest cases, so it’s always good to refresh ourselves on what they can or cannot do in these instances.

Note that everything in the attached protocol is Standing Order, which, as a reminder, consist of the steps that EMS providers should be performing by default without any additional physician input.

At the CFR level, providers who encounter a patient in arrest will initiate CPR and apply an Automated External Defibrillator, following the AED’s instructions until backup arrives.

BLS providers (EMTs) will request ALS backup if not already present, but will otherwise begin to transport the patient to the hospital after 3 rounds of CPR/AED analysis.

It’s not until the ALS (paramedic) level that an actual cardiac monitor will be applied, giving a specific rhythm underlying the arrest. It’s for this reason that you might hear something from the paramedics like “our initial rhythm was asystole; patient was shocked 2 times (by AED) prior to our arrival.” From there, paramedics will branch off into separate protocols based on the specific type of arrest, each consisting of their own Standing Orders and Medical Control Options.

Can’t wait to find out more specifics? Tune in next week for more cardiac arrest talk! Or, for spoilers, there’s always www.nycremsco.org and the protocol binder!

Dave

EMS Protocol of the Week - Introduction

Another year, another trip around the sun, and just as the sun rises and falls, just as the seasons change, so too do you have another EMS PoTW email gracing your mailbox. 

Interns, fellows, and new faculty, welcome to the Maimo fam! These emails, while destined to be your favorite part of every week, will start to make more and more sense after you get your lecture and hands-on time with the On-Line Medical Control (OLMC) phone. Until then, use these emails as a reference going forward!

Everyone else, welcome back! This week feels as good a time as any to reinforce some OLMC basics, starting with how to read these protocols (found here, at www.nycremsco.org, and the protocols binder next to the phone [you know, the one you always pick up by mistake]). Take a look at the attached pdf for a refresher on protocol formatting, but here are the big points:

1. Each protocol is divided into dedicated sections for CFR (firefighters), BLS (EMTs), and ALS (paramedics).

2. Each protocol reads top to bottom, in sequential order, but each section builds on the section before it (remember, “Good ALS care starts with good BLS care”). CFRs will stop at the end of their section, EMTs will cover everything between the CFR section and the BLS section, and paramedics will cover everything from the CFR, BLS, and ALS sections.

3. Standing Orders (SO) describe everything explicity written in each of these sections that EMS providers are expected to do by default. Medical Control Options (MCOs) are found at the end of each protocol and describe what providers (usually paramedics) can do after calling OLMC for physician approval; the most common example of this would be paramedics requesting to give calcium chloride and sodium bicarbonate during a cardiac arrest.

   1. Discretionary Orders (DO) are those that you, as the OLMC physician, are requesting the providers to perform but are not explicitly written in the protocols as either SO or MCO. The order must be for something that the crew already carries and is trained in using; a common example for this is having our paramedics use ketamine for intubation, because they use it in another protocol (Excited Delirium), and it’s not currently listed as a sedation option for airway management. On the flip side, you cannot ask the crew to give propofol as a Discretionary Order, as this is not a medication that they carry or know how to use. Discretionary Orders highlight the importance of having a general understanding of what EMTs and paramedics can do and how their ambulances are stocked.

   2. While we use 18 as the age cutoff for whether or not a patient is a minor, for the purposes of these protocols, the NYC REMAC defines pediatric patients as up to 15 years of age.

Let all of that simmer like a nice, hot, mid-July soup, and we’ll see it put into practice next week! Until then, don’t forget about www.nycremsco.org and the protocols binder.

Dave