Rosen & Barkin's 5-Minute Emergency Medicine Consult (676 page)

Procedural sedation:

• Etomidate: 0.1 mg/kg IV
  
• Fentanyl: 1–2 μg/kg IV
  
• Ketamine: Peds: 1 mg/kg IV – up to 2 additional doses of 0.5 mg/kg IV PRN
  
• Midazolam: 0.01 mg/kg (peds: 0.05–0.1 mg/kg) IV q2–3min
  
• Propofol: Initial bolus 1 mg/kg IV, then 0.5 mg/kg q3min as needed (adults and peds)
  

FOLLOW-UP

• Posterior dislocations of the SCJ require admission for possible reduction in the OR and evaluation for potential intrathoracic complications.
  
• Coexisting injury significant enough to warrant hospitalization
  

• SCJ sprains
  
• Anterior dislocations of the SCJ without neurovascular compromise or other significant injury
  
• Appropriate outpatient orthopedic follow-up arranged
  

Outpatient referral to an orthopedist should be recommended for patients with any significant SCJ injuries.

• It is difficult to achieve long-term stability after closed reduction of dislocations, so close orthopedic follow-up is advisable.
  
• Simple sling sufficient for sprains
  
• Figure-of-8 dressing for more severe injuries
  
• Repeat MRI or CT imaging may be beneficial.
  
• Even for mild sprains and subluxations, high-risk activity should be avoided for up to 3 mo.
  

• Since SCJ injuries are rare, this potentially life-threatening injury may be missed during ED evaluation and resuscitation.
  
• Posterior dislocations mandate early thoracic and cardiothoracic surgery consultation.
  
• Posterior dislocation may be mistaken for anterior due to marked swelling over the joint.
  
• In the pediatric population, a Salter–Harris fracture may mimic a dislocation.
  

• Buckley BJ, Hayden SR. Posterior sternoclavicular dislocation.
  J Emerg Med
  . 2008;34:331–332.
  
• Chotai PN, Ebraheim NA. Posterior sternoclavicular dislocation presenting with upper-extremity deep vein thrombosis.
  Orthopedics.
  2012;35:e1542–e1547.
  
• Groh GI, Wirth MA. Management of traumatic sternoclavicular joint injuries.
  J Am Acad Orthop Surg
  . 2011;19:1–7.
  
• Jaggard MK, Gupte CM, Gulati V, et al. A comprehensive review of trauma and disruption to the sternoclavicular joint with the proposal of a new classification system.
  J Trauma
  . 2009;66:576–584.
  
• Robinson CM, Jenkins PJ, Markham PE, et al. Disorders of the sternoclavicular joint.
  J Bone Joint Surg Br
  . 2008;90(6):685–696.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Acromioclavicular Joint Injury
  
• Arthritis, Septic
  
• Clavicle Fracture
  
• Trauma, Multiple
  

CODES

• 839.61 Closed dislocation, sternum
  
• 848.41 Sprain of sternoclavicular (joint) (ligament)
  

BASICS

• Stevens–Johnson syndrome (SJS) is an idiosyncratic, severe mucocutaneous disease:
  
  • Blistering of <10% of the body surface area (BSA)
    
  • 95% of patients have mucous membrane lesions:
    
    • Usually at 2 or more sites
      
  • 85% have conjunctival lesions
    
  • Lesions often involving face, neck, and central trunk regions become confluent over hours to days
    
• On a continuum with toxic epidermal necrolysis (TEN); but thought to be a distinct disease entity from erythema multiforme (EM):
  
  • SJS: <10% of BSA
    
  • SJS–TEN overlap syndrome: 10–30% of BSA
    
  • TEN: >30% of BSA, can affect up to 100% BSA
    

• The most common causes include medications and infections:
  
  • Damage to the skin is thought to be mediated by cytotoxic T lymphocytes and mononuclear cells aimed at keratinocytes expressing (drug-related) antigens
    
  • Cytokines from activated mononuclear cells probably contribute to cell destruction and systemic manifestations
    
• Causative medications:
  
  • Antibiotics (e.g., penicillin, sulfonamide)
    
  • Anticonvulsants
    
  • Oxicams
    
  • NSAIDs
    
  • Allopurinol
    
• Infections:
  
  • Mycoplasma pneumoniae
    
  • Herpes simplex
    

DIAGNOSIS

• Prodrome:
  
  • Usually 1–3 days prior to development of skin lesions
    
  • Fever
    
  • Headache
    
  • General malaise
    
  • Upper respiratory infection (URI) symptoms
    
  • Arthritis, arthralgias, and myalgias prior to mucocutaneous lesions
    
• Skin: Mild to moderate skin tenderness followed by skin pain, burning sensation, and paresthesias
  
• Eye: Conjunctival burning or itching
  
• Mucous membranes: Painful micturition, painful swallowing
  
• Drug exposure precedes symptoms usually by 2 wk:
  
  • Re-exposure may result in onset of symptoms within 48 hr
    
• Risk factors include HIV, genetic factors, viral infections, and underlying immunologic diseases
  

• Rash: Target lesions, erythematous or purpuric macules with or without confluence, and raised flaccid blisters or bullae with skin detachment that spread with lateral pressure (Nikolsky sign) on erythematous areas
  
• Mucous membrane: Erythematous tender erosions of the mouth, pharynx, trachea, genitalia, or anus; possibly pseudomembrane formation
  
• Eye: Mild to severe conjunctivitis with possible formation of pseudomembranes and corneal ulcers
  

A complete history and physical exam with careful attention to mucous membranes, percentage of blistering, and identification of likely etiology

• Electrolytes
  
• Liver enzymes may be mildly elevated
  
• CBC:
  
  • Anemia and lymphopenia are common
    
• UA
  

Chest radiography if pneumonia is a consideration

Skin biopsy of lesions and mucous membranes demonstrates necrosis of the entire epidermal layer with formation of subepidermal split above basement membrane

• SJS if <10% of BSA
  
• Overlapping SJS and TEN (skin detachment between 10% and 30% of BSA plus widespread macules or flat atypical target lesions)
  
• TEN (skin detachment >30% of the BSA plus widespread macules or flat atypical targets)
  
• EM
  
• Thermal burns
  
• Phototoxic reactions
  
• Exfoliative dermatitis
  
• Pustular drug eruptions
  
• Bullous fixed drug eruptions
  
• Paraneoplastic pemphigus
  
• Graft-versus-host disease in bone marrow transplant patients
  
• Toxic shock syndrome
  
• Staphylococcal scalded skin syndrome
  

Staphylococcal scalded skin syndrome is in the pediatric differential diagnosis of severe blistering mucocutaneous diseases

TREATMENT