http://www.medscape.org/viewarticle/749029
Above is a superb summary of current rabies and tetanus guidelines. While it is a video presentation, you can "speed things up" via advancing the slides. A few quick pearls (but again the summary is chock full of good information).
1. As a reminder, avoid closure as much as possible on bite wounds. If for "flap" reasons you need some type of closure, keep it as loose as possible, such as steri-strips over sutures.
2. Make sure your documented cleansing includes an antiviral agent, such as povidone-iodine or benzalkonium-chloride.
3. I think it started about 2 years ago, but for worried parents sent to the Health Department (ie- wild animal bite and animal not caught), the current rabies vaccine series is a total of four shots at days 0, 3, 7 and 14. Previously it was 5 doses.
4 The slide comparing high risk tetanus injuries versus low risk tetanus injuries is very useful...caution with the crush injuries!
5. Don't forget to check tetanus status for burns (as well as frostbite.)
Again- check out the presentation- you can even get CME for it at the end I believe.
Thursday, January 31, 2013
Stevens-Johnson Syndrome Reminder
http://www.jucm.com/magazine/members.php?issue=/magazine/issues/2013/0113/
While not the New England Journal of Medicine, this month's Journal of Urgent Care has a nice "reminder" article on maintaining your clinical suspicion for Stevens-Johnson Syndrome (pages 26-29 in the online magazine version. Note free registration may be required.)
Stevens Johnson Syndrome (SJS) is a tragic disease for the patient because of its severity, and a tragic disease for the provider because it has grave implcations and is easily overlooked, especially at first/initial presentation. A few key pearls:
1. To be safe, it is a good mental exercise for any patient with a rash to query and possibly examine for any mucus membrane involvement, since by definition SJS involves mucus membranes. Toxic epidermal necrosis, which is even more fatal and problematic, has larger expanses of mucosal involvement. Recall mucus membranes can include the vagina, sclera and conjunctiva, and the oral mucosa. As such, ask about eye discharge, blurry vision, vaginal discharge, and other mmebranous areas in your history and physical. I think out of routine most medical providers just "look in the mouth" and may forget other areas.
2. The list of tiggger medications for SJS are legion, but include TNF-x modulators, anti gout meds, antipsychotics, anticonvulsants, and of course antibiotics, especially the "textbok" sulfonamides as well as penicillins. So, basically the entire American public is at risk. All kidding aside though, keep this in mind if a patient returns from a recent visit for community acquired MRSA and was placed on Bactrim.
3. Being an urgent care, send the SJS patient to the emergency room. This disease, while technically less severe than TEN, can be fatal, and as the article bluntly states, " Patients with SJS burn from the inside out." As such the ER is the best place for burn treament, IV therapy and a proper pain regimen.
Respect SJS and remain vigilant for it by thoroughly reviewing your medication list, and taking seriously any rash that also includes mucosal involvement.
While not the New England Journal of Medicine, this month's Journal of Urgent Care has a nice "reminder" article on maintaining your clinical suspicion for Stevens-Johnson Syndrome (pages 26-29 in the online magazine version. Note free registration may be required.)
Stevens Johnson Syndrome (SJS) is a tragic disease for the patient because of its severity, and a tragic disease for the provider because it has grave implcations and is easily overlooked, especially at first/initial presentation. A few key pearls:
1. To be safe, it is a good mental exercise for any patient with a rash to query and possibly examine for any mucus membrane involvement, since by definition SJS involves mucus membranes. Toxic epidermal necrosis, which is even more fatal and problematic, has larger expanses of mucosal involvement. Recall mucus membranes can include the vagina, sclera and conjunctiva, and the oral mucosa. As such, ask about eye discharge, blurry vision, vaginal discharge, and other mmebranous areas in your history and physical. I think out of routine most medical providers just "look in the mouth" and may forget other areas.
2. The list of tiggger medications for SJS are legion, but include TNF-x modulators, anti gout meds, antipsychotics, anticonvulsants, and of course antibiotics, especially the "textbok" sulfonamides as well as penicillins. So, basically the entire American public is at risk. All kidding aside though, keep this in mind if a patient returns from a recent visit for community acquired MRSA and was placed on Bactrim.
3. Being an urgent care, send the SJS patient to the emergency room. This disease, while technically less severe than TEN, can be fatal, and as the article bluntly states, " Patients with SJS burn from the inside out." As such the ER is the best place for burn treament, IV therapy and a proper pain regimen.
Respect SJS and remain vigilant for it by thoroughly reviewing your medication list, and taking seriously any rash that also includes mucosal involvement.
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