brock8024 Posted November 29, 2006 Author Posted November 29, 2006 are the blisters on his feet as well? What started first the blisters in his mouth or on his hands? I might also want to know what kind of work this guy does and what kind of chemicals he has been using at the job site. Blisters in his mouth started first. He is a high school english teacher.
ERDoc Posted November 29, 2006 Posted November 29, 2006 Brock, I believe these are what you are trying to describe. Let me know if I am wrong and I will delete these so that I don't throw anyone off. Also, looking over the thread again, I have a question. Brock, why exactly did this guy or his wife call the ambulance? Did he have another seizure or was it for the rash? Someone had mentioned sepsis. Sepsis is definitely a possibility (especially with those VS), but what is causing the sepsis, anyone besides Brock? Do you need to use full PPE for transporting this pt? Why or why not? Let's recap a little here: You have an adult male who developed new onset seizures about 3 weeks ago and was started on phenytoin. About 1 week ago he developed a rash on his trunk and arms that looks like small targets. He was started on Bactrim for the rash and there has been no improvement. There is a questionable fever. He is hypotensive and tachycardic. He also has lesions in his mouth. This is a complicated case because there is so much going on. You have to sort through the details and figure out what is important here and what is just a red herring. This is probably something you have not learned about in EMT class. It is something that can be considered an emergency and although there is very little to do for it in the field it may determine where you take your pt. Hope I havne't given away too much here.
bassnmedic Posted November 29, 2006 Posted November 29, 2006 I'm probably would say that the patient is having severe side effects from the Bactrim and could be leading to Erythema Multiforme which could lead to Toxic Epidermal Necrolysis. Sounds like he is having Stevens- Johnson Syndrome right now. Take care, Todd
brock8024 Posted November 29, 2006 Author Posted November 29, 2006 I'm probably would say that the patient is having severe side effects from the Bactrim and could be leading to Erythema Multiforme which could lead to Toxic Epidermal Necrolysis. Sounds like he is having Stevens- Johnson Syndrome right now. Take care, Todd You got it he is having SJS which was caused from his Seizure med and the bactrium. Now what is the difference between the two. When does it go from SJS to TEN
bassnmedic Posted November 29, 2006 Posted November 29, 2006 Both SJS and TEN are types of Erthema Mutliforme, which is divided into 2 clinical types major and minor. Both SJS and TEN fall under the major category and are marked by toxicity and involvement of 2 or more mucosal surfaces, and both are better treated in a burn unit with discontinuation of the inciting Rx. take care, Todd
bassnmedic Posted November 30, 2006 Posted November 30, 2006 oh yeah, I forgot to mention that TEN has more BSA covered than SJS. Take care, Todd
ERDoc Posted November 30, 2006 Posted November 30, 2006 Erythema Multiforme(EM), Stevens Johnson Syndrome(SJS) and Toxic Epidermal Necrolysis(TEN) are all believed to represent the same disease process over a spectrum of severity, although there is great debate about this as some people believe that they represent different diseases with similar symptoms. The least serious is EM which is basically just a rash with possibly one mucosal (lips, mouth, anus, rectum, GU tract) surface involved. SJS is the next severe. It involves at least two mucosal membranes. These pts can be very sick, and even septic because of the exposed skin. They should be treated as burn pts. The most severe is TEN where you actually get necrosis of the epidermis. These are the sickest. Any of these can be caused by drugs(anticonvulsants, NSAIDs, antibiotics, Allopurinal and steroids being the most common), viruses or it can be idiopathic. For the prehospital environment, fluids and pain control are your treatment. Emedicine has a few good article and pictures for your enjoyment (I'm too lazy right now to provide the links, sorry).
bassnmedic Posted November 30, 2006 Posted November 30, 2006 SJS and TEN are generally differentiated by the BSA covered, TEN is more than 10% BSA and SJS is less than 10%, but as ErDoc stated, these are some pretty sick patients and need volume replacement and tx in a burn unit. Take care, Todd
melangel16 Posted November 30, 2006 Posted November 30, 2006 Can't say I've heard of any of this - if I saw it n the field, I'd take him to whatever hospital he has been dealing with or the one his doctor works out of and let them figure it out. Nothing we can do anyways besides supportive care- he can always be transferred to the burn unit after diagnosis. Thanks for the insight though.
brock8024 Posted December 2, 2006 Author Posted December 2, 2006 Right now I am working in a burn center and got to see this. It was interesting to see this. From what I have read most medics could possibly pick up on this depending what stage it was in. I love this board because I think it is a great learning place with all the interesting things we learn here. Brock
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