General internal medicine handbook Flashcards

1
Q

What is treatment for BDZ overdose?

A
  • Supportive measure is the mainstay of treatment
  • Flumazenil: the aim is to reserve respiratory depression.
  • Start with 0.2 mg IV, wait for 30 secs and titrate up to 1–2 mg in total
    C/I : patient with undifferentiated coma, epilepsy, benzodiazepine dependence, co-ingestion of pro-convulsion poisons; e.g. TCA
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2
Q

What is the treatment of opioid overdose?

A
  • Supportive measure is the mainstay of treatment
  • Naloxone: the aim is to reserve respiratory and/or CNS depression. - Start with 0.4 mg IV, wait for 60 s and titrate up to 2 mg in total.
  • For chronic user, start with low dose of 0.1 mg.
  • Naloxone infusion if repeated administration of naloxone needed.
    (2/3 of initial effective naloxone bolus on an hourly basis: i.e. 4initial effective dose + 500ml NS, Q6H).
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3
Q

What is the treatment of paracetamol overdose?

A
  • Acute toxic dose: >150 mg/kg
  • Activated Charcoal if within 1st hour, N-acetylcysteine (NAC) if toxic level above Tx line
  • NAC has full protection if given within 8 hours post-ingestion, useful even on late administration
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4
Q

What is the management for immediately life threatening SVCO?

A

 Stabilize airway, breathing, circulation
 Urgent Oncology consultation for immediate chemotherapy for chemosensitive tumours
 Urgent endovascular stenting can provide the most rapid relief
without affecting subsequent tissue diagnosis. Total SVC occlusion and SVC thrombus are not absolute contraindications for stenting. Post stenting short-term anti-thrombotic therapy recommended e.g. dual antiplatelets for 3 months (if no contraindication).

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5
Q

What is the management for stable SVCO patients?

A

 Clinical examination and investigations targeted to establish tissue diagnosis by minimally invasive methods.
 Sputum cytology, serum AFP, βHCG levels, LN biopsy, pleural
fluid cytology/pleural biopsy, bone marrow biopsy, endoscopic
biopsy, image-guided biopsy.
 For suspected lymphoma, excisional biopsy of enlarged lymph node is essential ± bone marrow biopsy
Watch out for coexisting pericardial effusion/cardiac tamponade.

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6
Q

What is treatment of SVCO?

A

Empirical
Prop up for head elevation
Oxygen supplement
Dexamethasone 4 mg q6h iv

Disease-specific (Consult Oncology): Chemotherapy, Radiotherapy, Targeted therapy
Presence of SVC thrombus
 Thrombolysis (mechanical/pharmacologic) may be considered in patients with extensive thrombus causing severe symptoms, balancing risks of bleeding.
 Long term anticoagulation, if not contraindicated, for 3–6 months AND preferably continued beyond 6 months in those with active cancer or receiving chemotherapy (ASCO guideline 2015 update). LMWH is preferred over warfarin in malignancy-related thrombosis for its lower rate of recurrent thromboembolism and less drug interaction with subsequent systemic cancer therapy. Both have similar bleeding risks.

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7
Q

What is the general measures for acute poisoning?

A
  • Maintain ABC, close monitor vital signs and neurological status
  • External decontamination and beware of secondary contamination
  • Obtain history of offending poison, dose, dosage form (susained release (SR) preparation), timing of ingestion
  • Ix: CBP, L/RFT, glucose, H’stix, blood gas, lactate, osmolality. Urine, blood,+/-gastric contents for toxicology.
    Specific drug level: paracetamol, ethanol, salicylate, as indicated
    ECG (assess for HR, QRS, QTc, arrhythmia)
    Imaging for body packing or massive SR pills poisoning
    Correct fluid, electrolyte, acid/base disturbance and treat arrhythmia
    Psychiatry consultation, suicidal precautions as appropriate
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8
Q

What GI decontamination techniques may be considered for acute poisoning?

A
  • Activated charcoal: within first 1-2 hour after toxic ingestion. dose: 50-100g PO. Not for small molecuels (Fe, Li, toxic alcohols), caustic, hydrocarbon. Intubation and NG tube needed for unconsious patient. C/I: absent bowel sound or bowel perforation
  • Gastric lavage (GL): potentailly life threatening poisonous ingestion. Consious patient must be cooperative, consent signed, lying head down left lateral position, with powerful suction standby. 36-40F orogastric tube, 200-250ml water each time for at least 4-6L or until return fluid is clear
  • Multiple dose activated charcoal (MDAC): 1g/kg PO, followed by 0.5g/kg q2-4h for 1-2 days. Consider for theophylline, phenobarbital, phenytoin, digoxin, carbamazepine, dapsone, GI concretion forming drug; aspirin and sustained release preparation
  • Whole bowel irrigation (WBI): toxic dose of SR preparation, body packers and drugs not absorbed to AC. PEG 1-2L/hr till clear rectal effluent (orally or via a NG tube). C/I: absent bowel sound or bowel perforation
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9
Q

What is the use of antidotes and enhanced elimination as needed in acute poisoning?

A

Specific antidotes: level 1,2,3 antidotes kept at acute hospitals, cluster hospitals and HKPIC respectively

Enhanced elimination as needed
Urinary alkalinization
* Useful in aspirin, phenobarbital, chlorpropaide, formate, methotrexate
* 1-2mmol/kg NaHCO3- IV bolus, then 50 mmol NaHCO3 (8.4%) in 500ml D5 Q4-6H IV infusion
* Works by ion trapping, must get urine pH>7.5 to be effective

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10
Q

What is the treamtent and management for methamphetamine/amphetamine/cocaine overdose?

A
  • Agitation, hyperthermia: rapid cooling, IV BDZ
  • Diazepam 0.1-0.3mg/kg IV bolus; cumulative doses up to 50-100 mg may be required
  • HT: phentoalmine 1-5mg IV and repeat every 10 mins or nitroglycerin 0.25-5mg/kg.min
  • Avoid BB alone for the unopposed alpha sympathetic effects
  • Cocaine (Na channel blocking effect): NaHCO3- 1-2mmol/kg/ IV bolus till QRS <100ms or pH>7.55
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11
Q

What is the treatment of salicylate overdose?

A
  • > 150mg/kg acetylsalicylate (aspirin) potentially toxic
  • Pure methyl salicylate (oil of wintergreen): 10ml –> 14g of salicylate
  • Ix: R/LFT, blood gas, serial salicylate level, glucose, urine ketone
  • Consider GL, AC, MDAC, WBI
  • Hydration, urine alkalinization if ASA >40mg/dL
  • HD if end organ failure or ASA >100mg/dL or failed urine alkalinization
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12
Q

What is the treatment of anticholinergic poisoning?

A
  • Physostigmine in selected case: 0.5–1mg slow IV, repeat up to 2mg C/I: TCA, widen QRS, CV disease, asthma, gangrene.
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13
Q

What is the treatment of BB overdose/CCB overdose?

A
  • GI contamination, haemodynamic and cardiac monitoring
  • Treatment options for bradycardia and hypotension
  • Atropine: 0.6mg IV (up to 3mg) and iv fluid
  • Glucagon: 2-5mg IV over 1 min (up to 10mg) followed by 2-5mg.hr in D5 (for B blocker poisoning)
  • High dose insulin euglycemia therapy to enhance tissue perfusion (early use): regular insulin 1 units/kg IV bolus + dextrose 0.5g/kg/IV bolus. Regular insulin infusion starting at 0.5-2 units/kg/hr and increased by 2 units/kg/hour if no increase in cardiac output or clinical improveemnt up to 10 units/kg/hour
  • Inotropes: adrenaline (0.02mg/kg/hr/min and titrate up), noradrenaline (0.1mg/kg/min and titrate up), dobutamine (2.5mg/kg/min and titrate up), isoproterenol (B agonist): 0.1mg/kg/min and titrate up, vasopressin (2 IU/hr and titrate)
  • IV lipid emulsion: intralipid 20% 1.5ml/kg IV over 1 min, followed by 15ml/kg.hr over 30-45 min IV infusion
  • NaHCO3- 1-2mmol/kg IV bolus for propranolol poisoning if QRS >100ms, repeat as indicated
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14
Q

What is the treatment of digoxin overdose?

A
  • Ix: RFT, digoxin level, ECG
  • GI decontamination: consider GL, AC, MDAC
  • IVF to correct dehydration
  • Bradydysrhythmias: atropine
  • Tachydysrhythmia: Tx hypoK, hypoMg, lignocaine, amiodarone
  • Cardioversion: may precipitate refractory VT, VF, start with low dose: 10-25J, pre-Tx with lignocaine or amiodarone
    Digoxin immune Fab fragments (Digifab in HA) indications
  • Brady or ventricular arrhythmia not responsive to atropine
  • Serum K>5mmol/L in acute DO
  • Digoxin levle: 10-15ng/mL in an acute DO
  • Digoxin ingestion of >10mg
    Recommended dosage (50mg per vial) can be used with one of the below formulas
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15
Q

What is the management guideline for warfarin patient with over anti-coagulation?
Symptomatic and anti-Sx algorithm guideline

A
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16
Q

What is the treatment for dirct anticoagulant (DOAC) overdose?

A
  • Inquire about last DOAC intake
  • AC if within 2-4 hour of ingestion
  • General Mx: IVF replacement, endoscopic or surgical haemostasis, blood and plasma transfusion (as plasma expander)
  • For life threatening bleeding involving DOAC
  • For rivaroxaban, apixaban or endoxaban: PCC 50IU/kg IV; consider rF7a (novoseven) 90IU/kg.
  • For dabigatran: consider idarucizumab 5g IV; consider haemodialysis or haemoperfusion
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17
Q

What is the treatment for theophylline poisoning?

A
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18
Q

What is the treatment for sulphonylurea or insulin secretagogue poisoning?

A
  • AC, GL if ingestion <1 hr; consider MDAC / WBI in severe case
  • Oral feeding is allowed in conscious patient
  • Monitor conscious level, correct hypokalaemia, hypophosphataemia, hypoglycaemia
  • Consider thiamine 100 200mg IV prior to dextrose in alcoholic or malnourished patient
  • D50 0.5 1g/ kg IV bonus preferably through central line
  • Glucagon 5mg IM if fail to establish venous access
  • In refractory hypoglycaemia (requiring repeated dextrose IV bonus or
    escalating concentrated dextrose infusion), consider early use of octreotide 0.05 mg Q6H SC or IV (to reduce the risk of glucose-induced insulin release in SU poisoning)
  • Urine alkalinsation can be useful in chlorpromazine poisoning
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19
Q

What is general management of antipsychotics poisoning?

A
  • Supportive care, ECG, GI decontamination as indicated
  • Hypotension: IV fluid, inotropes
  • Cardiotoxicity, widen QRS: treat like TCAs
  • Dystonia: diphenhydramine 10mg IV or benztropine 1mg IM
  • Look out for neuroleptic malignant syndrome
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20
Q

What is the treatment for TCA overdose?

A
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21
Q

What is the treatment for SSRI overdose?

A
  • Supportive care, ECG,GI decontamination as indicated
  • Treatment for serotonin syndrome (SS) if present
  • Remove offending drugs, hydration, cooling, BDZ
  • Cyproheptadine (8-12mg, then 2mg q2h, up to 32mg in first 24hour), neuormuscular blockade
  • Citalopram: observe for >24 hour, cardiac monitoring (for prolonged QT, torsades de pointes (esp with dose >400mg)
  • Venlafaxine: seizure; esp with dose >1.5g, prolonged QRS
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22
Q

What is the treatment for lithium poisoning?

A
  • Ix: RFT, serum Lithium level q4h, AXR, ECG
  • Serum Li level correlates poorly with CNS toxicities
  • GI decontamination: GL, WBI
  • Volume replacement and correction of hypoNa

Haemodialysis indication
* Neurotoxicity (depressed consiousness, cerebellar signs, or convulsion) irrespective of Li level
* Impaired renal function
* Acute Li poisoning with serum Li level >5mmol/L
* Chronic Li poisoning with serum Li level >2.5 mmol/L
End point of HD
* Neurotoxicity subsided and
* Li level remains stable at <1mmol/L (serum Li level may rebound after stopping HD, continuous monitoring as needed after stopping HD)
Continous RRT is an acceptable alternative if HD is not available

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23
Q

What is the treatment for valproate overdose?

A
  • > 100-400mg/kg: potentially toxic
  • Ix: LDT, valproic acid (VPA) level q4-6h until a downward trend, ammonia, blood gas
  • Mod to severe toxicity may occur if VPA level >3100-5900umol/L
  • ABC monitoring and supportive measures
  • GI contamination: AC, GL/MDAC/WBI
  • Levocarnitine indication: encephalopathy, hepatoxicity, hyperammonemia, or VPA level >59900
  • Consider naloxone 0.4-2mg IV for CNS and respiratory depression
  • Consider HD or HF in very severe poisoning (remove free VPA in blood) if: encephalopathy, hyperammonemia, VPA level >5900 umol/L or metabolic acidosis pH<7.1
24
Q

What is the treatment for carbamazepine poisoning?

A
  • Ix: carbamazepine levle q4-6h until a downward trend, ECG (widen QRS)
  • Life threatening toxicity may occur: carbamazepine level >170umol/L
  • ABC monitoring and supportive measures
  • ABC monitoring and supportive measures
  • GI decontamination: AC/MDAC
  • NaHCO3- for widen QRS >100ms (theoretically beneficial)
  • Haemoperfusion
25
Q

What is the treatment for organophosphate poisoning?

A
  • Decontamination and staff protection, supportive care
  • Muscarinic and/or nicotinic toxidromes can occur
  • ABC, supportive measures
  • Ix: plasma cholinesterase, ABG
  • Atropine for reversal of muscarinic toxicity: start with 0.6-1.2mg IV, repeat and double the dose every 5 min until achieivng end points: lung clear, HR>80bpm, SBP >80mmHg, and/or dry axillae (huge dose up to 1000mg/d may be required)
  • Consider early use of pralidoxime to prevent aging of acetylcholinesterase: 1-2g into 100ml NS over 30 min IV, followed by infusion at 8-10mg/kg/hr, can be titrated up to 20mg/kg/hour
26
Q

What is the treatment for carbamate poisoning?

A
27
Q

What is the treatment for paraquat poisoning?

A
28
Q

What is the treatment for household poisoning?

A
29
Q

What is the treatment for methanol/ethylene glycol (EG) poisoning?

A

Ix: Blood: CBP, LRFT, ethanol level, anion gap, osmolar gap, methanol or ethylene glycol level
Urine for Ca oxalate and fluorescence [in EG poisoning]

30
Q

What is the treatment for cyanide poisoning?

A
  • ABC monitoring and supportive measures
  • Surface decontamination and staff protection
  • Treat seizure, hypotension and correct metabolic acidosis
  • GI decontamination: consider AC +GL if ingestion within 1 hour
  • Ix: RFT, ABG, lactate, AV O2 gradient (PaO2-PvO2), CO-Hb, met-Hb, blood cyanide level (confirm dx but not affect initial mx). Early use of antidotes in clinically suspected case: lactate >7mmol/L, high anion gap metabolic acidosis and reduced AV O2 gradient
31
Q

What is the treatment for methaemoglobinemia?

A
  • Suspect clinically in patient with persistent cyanosis despite oxygenation and without cardiopulmonary etiology
  • ABC monitoring and supportive measures.
  • Pulse oximeter cannot detect Met-Hb, can be misleading
  • Treat seizure, hypotension and correct metabolic acidosis
  • GI decontamination: consider AC if ingestion within 1 hr
  • Ix: RFT, ABG, lactate, CO-Hb, met-Hb
  • Methylene blue: 0.1–0.2 ml/kg of 1% (1–2 mg/kg) IV over 5 min, (Repeat in 30-60 min if no response)
  • Indications:
     Met-Hb >30%; or
     Met-Hb >20% with symptoms or signs of tissue hypoxia
32
Q

What is the treatment for carbon monoxide poisoning?

A
  • Pulse oximeter cannot detect CO-Hb; can be misleading
  • look for features of tissue hypoxia (CNS,cardiac,metabolic)
  • CO-Hb does not correlate clinical severity and/or outcome
  • Indications for consideration of Hyperbaric oxygen treatment(HBO)
    Loss of consciousness, coma, seizures
    Confusion, cognitive deficits, focal neurological findings, visual symptom
    Myocardial ischemia, life threatening arrhythmias
    Persistent symptoms (after normobaric O2): headache, ataxia, abnormal
    neuropsychiatric test
    CO-Hb level > 25% or >15% if pregnant woman / child
33
Q

What is the management for pulmonary irritant inhalation?

A
34
Q

What is the management algorithm for smoke inhalation?

A
35
Q

What are the SS for snake bite?
What Ix should be done?

A
36
Q

What is the treatment for snake bite?

A
37
Q

Define hypothermia
What are the Ix and Mx for accidental hypothermia?

A
38
Q

Define heat stroke
Compare the features of heat stroke vs heat exhaustion
What is the management?

A
39
Q

What is the Ix and Mx for near drowning patients?

A
40
Q

What is the Ix and Mx for electrical injury?

A
41
Q

What are the clinical features and lab findings for rhabdomyolysis?

A
  • Red or brown urine +ve for blood but no RBC under microscopy
  • Urine +ve for myoglobin
  • Pigmented granular casts in the urine
  • Increased CK level
  • Others: hyperkalaemia, hypoCa, hyperP, hyperuricaemia, DIC, Acute Kidney Injury.
42
Q

What is the Mx of rhabdomyolysis

A
43
Q

What is the causes of SVCO?
PE
DDx
Ix
Tx

A
44
Q

What are the main causes of malignancy related superior vena cava syndrome?
What are the Ix done for immediately life threatening situation? For stable/stabilized patients?

A

Causes (malignancy accounts for 80% of SVCO):
* NSCLC (50%), SCLC (25%), non hodgkin lymphoma (10%). Others e.g. germ cell neoplasms, breast carcinoma, thymoma etc

Treatment is tailored to the specific neoplasm; therefore, tissue dx is essential prior to empirical treatment, which would jeopardized histological evaluation e.g. corticosteroid in lymphoma, radiotherapy

Ix for immediately life threatning situations e.g. upper airway obstruction due to tumor compression or severe laryngeal edema, impaired consious state due to cerebral edema
* Stabilize ABC
* Urgent oncology consultation for immediate chemotherapy for chemosensitive tumors
* Urgent endovascular stenting can provide the most rapid relief without affecting subsequent tissue dx. Total SVC occlusion and SVC thrombus are not absolute contraindications for stenting. Post stenting short term antithrombotic therapy recommended e.g. DAPT for 3 months (if no contraindication)

For stable/stabilized patients
* Clinical exam and Ix targeted to establish tissue dx by minimally invasive methods
* Sputum cytology, serum AFP, BhCG levels, LN biopsy, pleural fluid cytology/pleural biopsy, bone marrow biopsy, endoscopic biopsy, image guided biopsy
* For suspected lymphoma, excisional biopsy of enlarged LN is essential + bone marrow biopsy
* Watch out for coexisting pericardial effusion/cardiac tamponade

45
Q

What is the Tx for malignancy related superior vena cava syndrome?

A
46
Q

What are the causes of hypercalcemia of malignancy?
What is oncology workup?

A
47
Q

What is hte Ix, Dx, prophylaxis and Tx for tumor lysis syndrome?

A
48
Q

Define extravasation of chemotherapeutic agents and what are common vesicants?
How to porevetn extravasation?
What is the Mx when extravasation is suspected?

A
49
Q

What are the preconditions and exclusions for considering dx of brain death?

A
50
Q

What are the tests for confirming brain death?

A
  • All brainstem reflexes must be absent.
  • The testing of all the following is considered sufficient
    a) Both pupils: fixed in diameter and non-reactive to light
    b) Absence of bilateral corneal reflexes
    c) Absence of VOR: no eye movement occurs in both eyes during or after the slow injection of at least 50ml ice cold water into at least 1 external auditory meatus or preferably into each external auditory meatus in turn.
    d) No motor responses within the trigeminal nerve distribution can be elicited by adequate pain stimulation of any somatic area
    e) Absence of gag reflex
    f) Absence of cough reflex
    g) Testing for apnea: should be done last. No respiratory movements occur when the patient is disconnected from the mechanical ventilator for long enough to ensure that the pCo2 rises above the threshold for stimulating respiration. In patients with pre-existing hypercapnia, it is recommende to wait for a pCO2 rise of >2.7kPa above the chronic level, with a pH<7.3. ABG must be available for this test to be performed.

Period of observation and reteption of tests: 2 separate full exams should be performed. The 1st exam should be performed after all pre-conditions met, and after at least 4 hours of observation of coma (GCS of 3) with absent brainstem function. 2nd exam can be performed any time after 1st exam, so total period of observation is at least 4 hours. The minimum period of observation needs to be totally 24 hours after cardiorespiratory arrest.

51
Q

What is the clinical featrures of SJS and TEN?
What percentage of epidermal detachment?

A
52
Q

What are causes of SJS/TEN?
What are other organ involvement complications?

A

Drugs implicated in 70-80% of SJS/TEN

Common culprit drugs
* Allopurinol (check HLA-B * 5801 if indicated)
* Aromatic anticonvulsants (phenytoin, carbamazepine (HLA-B * 1502) and phenobarbital
* Antibiotics
* Sulphonamides
* NSAID

other organ involvement complications
* Seconbdary bacterial infection and septicemia
* Dehydration
* Electrolyte imbalance
* Pre-renal azotaemia
* Thermal dysregulation
* Adult respiratory distress syndrome

53
Q

What is initial assessment workup for SJS/TEN?

A

 Obtain detailed history from patient/relatives including clear drug history
 Drug history elicited should include: name of medication, reason for intake, interval between drug administration and cutaneous reaction, duration of drug administration, prior exposure to same or a cross-reacting medication, concurrent medications
 Stop suspected culprit drug if identified
 Take blood for Mycoplasma serology/swab for Herpes simplex virus culture/PCR study (if no culprit drug identified)
 Take blood for CBC, LRFT, bicarbonate, glucose, urine
microscopy, perform CXR
 Skin swab for pyogenic culture
 Take skin biopsy – send for Histology (lesional) and direct
Immunofluorescence stain (peri-lesional area) in fresh specimen
 Establish peripheral venous access
 Consider nasograstic (NG) tube and foley catheterization
 Consult ICU, Dermatology, Ophthalmology, ENT, Plastic
Surgery/Burns Team for assessment
 Additional clinical input to multidisciplinary team may be
required from respiratory medicine, gastroenterology, gynaecology, urology, pain team, and microbiology may be required

54
Q

What are the prognostic factors for SJS/TEN?

A
55
Q

What is the treatment for SJS/TEN?

A
  • Transfer to burns/ICU: patient with >10% BSA epidermal loss should be considered admission without delay to ICU/burns unit with experience in treating patients with SJS/TEN. Pressure relieving mattress in a room with controlled humidity and temperature
  • Prompt withdrawal of causative drug
  • Prevention, early detection and treatment of infections: sepsis related mortality in TEN patients are staph aureus and psuedomonas aeruginosa. Antibiotics should only be initiated if there are signs of sepsis.
  • Wound care
    Mucosal lesions: oral toilet and hygience, saline compress, chlorhexidine wash
    Non infected skin: non adherent dressings (e.g. petroleum, impregnated gauzes, silicone dressings). Primary dressings secured with roller gauze bandages and elastic tubular dressings e.g. tubifast and changed every 2-4 days.
    Infected wounds: consider dressing with antimicrobial properties such as silver e.g. Mepilex Ag, Aquacel Ag
  • Fluid, electrolytes and nutrition (urinary catheterization should be considered in all cases) Maintain urine output of 0.5-1ml/kg/hour. Treat hyperglycemia. Consider LMWH in immobile patients. Consider PPI to reduce stress related GI ulcerations.
  • Respiratory care: respiratory toilet (nebulized saline, bronchodilators)
  • Ocular involvement (refer to opthalmologist): preservative free lubricants, topical steroids and topical antibiotics. Prevent corneal exposure in unconsious patient
  • Oral involvement: use antiinflammatory oral rinse or spray containing benzylamine hydrochloride e.g. difflam mouthwash, every 3 hours. Anti antiseptic oral rinse containing chlorhexidine twice a day. Use a potent topical corticosteroid spray to oral sores (e.g. betamethasone sodium phospahte 500ug or fluticasone propionate spray 50ug 2 dose unit sprays 4x a day)
  • Urogenital involvement: apply white soft paraffin ointment to the urogenital skin and mucosae every 4 hours through acute illness. To eroded areas: use silicone or non adherent dressing e.g. paraffin gauze dressing
  • Pain control: tramadol and morphine
56
Q

What is the discharge and follow up for SJS/TEN?

A