Flashcards in MTB Dermatology/emergency Deck (37):
Kaposi sarcoma treatment
Seborrhoeic keratoses, premalignant?
Atopic dermatitis is a common skin disorder associated with...
overactivity of mast cells and the immune system. Look for a history of:
• Allergic rhinitis
• Family history of atopic disorders
• Onset before age 5, very rare to start after age 30
1. Topical high-potency steroids: fluocinonide, triamcinolone, betametha-sone, clobetasol
2. Vitamin A and vitamin D ointment help get the patient off steroids. The vitamin D agent is calcipotriene. Steroids cause skin atrophy.
3. Coal tar preparation
4. Pimecrolimus and tacrolimus are used on more delicate areas such as the face and penis. They are an alternative to steroids and are less potentially deforming.
1. Ultraviolet light
2. Antitumor necrosis factor (TNF) inhibitors (etanercept, adalimumab, inflixirnab). These agents can be miraculous in efficacy for severe disease.
3. Methotrexate: used last because of adverse effects on the liver and lung. It is a drug oflast resort except for psoriatic arthritis.
Eczema skin treatment
Avoid bath, soap, and washcloths
Tacrolimus and pimecrolimus
Antibiotics if impetigo
Pityriasis rosea is...
an idiopathic, transient dermatitis that starts out with a single lesion (herald patch) and then disseminates. It can look like secondary syphilis but it spares the palms and soles. It is transient, but if symptomatic it is treated with steroids or ultraviolet light.
This is a much milder disease than pemphigus because:
• Bullae stay intact and there is less loss of fluid and infection. • Mouth involvement is uncommon.
Nikolsky sign absent
Pemphigus vulgaris (Blistering Diseases)
Associated with ACEi
Autoantibodies split the epidermis, resulting in:
• Bullae that easily rupture because they are thin walled • Involvement of the mouth • Fluid loss and infection if widespread; they act like a burn
Biopsy to Dx
weeping, crusting, oozing, and draining of the skin.
a much more severe disease than impetigo because it occurs at a deeper level in the skin. Erysipelas is much more often from Streptococcus than Staphylococcus.
Treatments for erysipelas, cellulitis, folliculitis, furuncles, and carbuncles.
Mild disease: Use oral medications:
• Penicillin, dicloxacillin, cephalexin, cefadroxyl
• Penicillin allergic: erythromycin, clarithromycin, or clindamycin
• MRSA: doxycycline, trimethoprim/sulfamethoxazole
Severe disease (fever present): Use intravenous medications:
• Oxacillin, nafcillin, cefazolin
• Penicillin allergic: clindamycin, vancomycin
• MRSA: vancomycin, linezolid, daptomycin, tigecycline, ceftaroline
If the reaction to penicillin is a rash, use cephalosporins.
If the reaction is anaphylaxis:
• Mild infection: macrolides, clindamycin, doxycycline, or TMP/SMZ
• Severe infection: vancomycin, or ceftaroline
Skin drug reactions
Morbilliform rash: mildest reaction. Skin stays intact without mucous mem-1 brane involvement. No specific therapy.
Erythema multiforme: widespread, small "target" lesions; most are on the trunk. No mucous membrane involvement. May also be from herpes or myco-plasma. Prednisone may benefit some patients.
Stevens-Johnson syndrome: very severe. Involves the mucous membranes. Sloughs off respiratory epithelium and may lead to respiratory failure. Steroids not clearly beneficial. Use intravenous immunoglobulins (IVIG).
Toxic epidermal necrolysis (TEN): rash with mucous membrane involvement and adds Nikolsky sign. Steroids definitely do not help. Treat with IVIG.
SSSS and TSS
Staphylococcal scalded skin syndrome (SSSS) and toxic shock syndrome (TSS) are different severities of the same event: a reaction to a toxin in the surface of Staphylococcus.
SSSS looks similar to TEN, including Nikolsky sign. TSS has the same skin involvement as well as life-threatening multiorgan involvement such as:
• Hypotension • Renal dysfunction (elevated BUN and creatinine) • Liver dysfunction • CNS involvement (delirium)
The best initial management of altered mental status of unclear etiology is
an opiate antagonist and glucose.
Naloxone and dextrose
Aspirin overdose causes...
• Tinnitus and hyperventilation
• Respiratory alkalosis progressing to metabolic acidosis
Drug induced seizures
Although flumazenil can cause seizures from reversing chronic benzodi-azepine dependence, this case quite specifically states the benzodiazepine ingestion was today only. Benzodiazepines, however, can prevent seizures from tricyclic toxicity. When you reverse the benzodiazepines, you remove the suppression of the tricyclic toxicity. Opiate withdrawal does not cause seizures. Cocaine toxicity causes seizures, not withdrawal. Coingestion of tricyclics and benzodiazepines is very common.
Tricyclic antidepressant toxicity is rapidly detectable on
EKG. The EKG will show widening of the QRS complex. Torsade de point
Tricyclic antidepressant (TCA) toxicity can cause
seizures and arrhythmia leading to death. A wide QRS will tell who is about to have an arrhythmia. TCAs cause signs of anticholinergic effects such as:
• Drymouth • Constipation • Urinary retention
None of these effects causes death.
Treatment of TCA overdose is with sodium bicarbonate. Bicarbonate will protect the heart against arrhythmia. The bicarbonate does not increase uri-nary excretion of TCAs as it does for aspirin.
Carbon monoxide poisoning
CO binds oxygen to hemoglobin so tightly that carboxyhemoglobin will not release oxygen to tissues. Carboxyhemoglobin acts functionally like anemia. There is no functional difference between the absence of blood and carboxyhemoglobin; 60% carboxyhemoglobin acts like the loss of 60% of blood. CO poisoning presents with dyspnea, lightheadedness, confusion, sei-zures, and ultimately death from a myocardial infarction.
pH 7.35 pC02 26 HC03 18
Carbon monoxide poisoning prevents oxygen release to tissues, so lactic acidosis develops.
Brown oxidized hemoglobin that cannot carry oxygen.
Caused by anesthetics, nitrates
Carbon is abnormally red
Methemoglobinemia is brown
Predisposed by hypokalemia
GI nausea vomiting
Visual yellow halo
PPI is given to prevent stress ulcer when...
• Endotracheal intubation
• Coagulopathy (platelets below 50,000 or INR over 1.5) with respiratory failure
Unsynchronized cardioversion when...
VF and pulseless FT
Palpitations, dizziness, or lightheadedness
Exercise intolerance or dyspnea
Synchronization cardioversion helps...
prevent deterioration into VT or VF.
SVT The best initial step is:
1. Vagal maneuvers (e.g., carotid massage, Valsalva, dive reflex, ice immersion) 2. Adenosine if vagal maneuvers don't work 3. Beta blockers (metoprolol), calcium channel blockers (diltiazem), or digoxin if adenosine is not effective
C: CHF or cardiomyopathy
A: age >75
S: stroke or TIA = 2 points
When CHADS score is 1 or less, use aspirin. When CHADS score is 2 or more, use warfarin, dabigatran, or rivaroxaban.
• More sun, more cancer
Skin cancer ABCDE
B: border irregularity
C: color irregularities
D: diameter greater than 6 millimeters
E: evolution (changing in appearance over time)
must be removed with curettage, cryotherapy, laser, or topical 5-fluorouracil before they transform. The local immunostimulant imiquimod is also effective.
superficial fungal infection = tinea
When the answer is not clear and the cause of overdose is asked, say:
• Acetaminophen • Aspirin
• Opiate overdose is fatal:
• Benzodlazeplne overdose by itself is
Give naloxone immediately.
not fatal and acute withdrawal causes seizures. Do not give flumazenll.
xxx is benign and should be given to anyone with a pill overdose.