Rosen & Barkin's 5-Minute Emergency Medicine Consult (677 page)

• ABCs
  
• Observe universal precautions
  
• IV access if indicated
  
• Transport to burn center if >30% of body surface involved
  

• Endotracheal intubation and ventilatory support may be required for impending respiratory failure (more commonly associated with TEN)
  
• IV fluids
  

• Fluid replacement:
  
  • Fluid losses may be significant
    
• Recognize and treat underlying infections:
  
  • Sepsis is the primary cause of death, frequently from gram-negative pneumonia
    
  • Secondarily infected cutaneous lesions can be treated with débridement of blisters, compresses, and systemic antibiotics
    
• Corticosteroids are controversial
  
• Prophylactic antibiotics may be indicated if systemic steroids are given
  
• Intravenous immunoglobulin (IVIG) may be beneficial
  
• Mild systemic symptoms may be treated with acetaminophen or NSAIDs provided they are not the cause of the mucocutaneous reaction
  
• Mucous membrane lesions are extremely painful and may require parenteral analgesics
  
• Large extensive bullae should be débrided, ideally in a burn unit
  

• Acetaminophen: 500 mg PO/PR q4–6h (peds: 10–15 mg/kg/dose; do not exceed 5 doses/24 h); do not exceed 4 g/24 h
  
• Acyclovir: 5–10 mg/kg IV q8h (for herpes simplex virus infections)
  
• Ibuprofen: 300–800 mg PO (peds: 5–10 mg/kg/dose)
  
• Morphine sulfate: 0.1 mg/kg/dose IV
  

• Fluid replacement
  
• Treat underlying etiology
  
• Treat secondary infections
  
• Analgesia
  

• IVIG
  
• Corticosteroids
  

FOLLOW-UP

• Patients with SJS should be admitted to the hospital
  
• Patients with extensive epidermal detachment should be admitted to a burn center or a specialized intensive care unit
  

Patients with EM minor may be discharged with appropriate and timely follow-up

Patients must be made aware of the likely offending drug (and its class) and that it must never be administered to them again

Follow-up with PCP and/or dermatologist

• SJS may begin like an influenza illness. Lesions appear 1–3 days after the prodrome
  
• The diagnosis is clinical and biopsy is supportive
  
• M. pneumoniae
  and herpes simplex are more common triggers in children than in adults
  

• Gerull R, Nelle M, Schaible T. Toxic epidermal necrolysis and Stevens-Johnson syndrome: A review.
  Crit Care Med.
  2011;39:1521–1532.
  
• James JD, Berger TG, Elston DM.
  Andrew’s Clinical Dermatology.
  10th ed. Philadelphia, PA: Saunders; 2006.
  
• Lee HY, Dunant A, Sekula P. The role of prior corticosteroid use on the clinical course of Stevens-Johnson syndrome and toxic epidermal necrolysis: A case-control analysis of patients selected from the multinational EuroSCAR and RegiSCAR studies.
  Br J Dermatol.
  2012;167:555–562.
  
• Levi N, Bastuji-Garin S, Mockenhaupt M, et al. Medications as risk factors of Stevens-Johnson syndrome and toxic epidermal necrolysis in children: A pooled analysis.
  Pediatrics
  . 2009;123:e297–e304.
  
• Stella M, Clemente A, Bollero D, et al. Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS): Experience with high-dose intravenous immunoglobulins and topical conservative approach. A retrospective analysis.
  Burns
  . 2007;33:452–459.
  
• Wolff K, Johnson RA, Suurmond D. Stevens-Johnson syndrome and toxic epidermal necrolysis. In:
  Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology.
  5th ed. New York, NY: McGraw-Hill, 2005:144–147.
  

See Also (Topic, Algorithm, Electronic Media Element)

• Erythema Multiforme
  
• Toxic Epidermal Necrolysis
  

CODES

• 695.13 Stevens-Johnson syndrome
  
• 695.14 Stevens-Johnson syndrome-toxic epidermal necrolysis overlap syndrome
  

BASICS

• Injection of hymenoptera venom causes:
  
  • Release of biologic amines
    
  • Local or systemic allergic reactions
    
• Reactions are:
  
  • Usually IgE-mediated type I hypersensitivity reactions
    
  • Rarely type III (Arthus) hypersensitivity reactions
    

• Hymenoptera—order of the phylum Arthropoda
  
• Includes bees (Apidae family), wasps and hornets (Vespidae family), fire ants (Formicidae family)
  

DIAGNOSIS

History and physical exam—keys to diagnosis

5 types of reactions to stings:

• Local reaction:
  
  • Most common type of reaction
    
  • Local pain, erythema, and edema at sting site
    
  • Symptoms occur immediately and resolve within 1–2 hr
    
• Large local reaction:
  
  • Similar to local reaction but affects larger area or entire limbs
    
  • Peaks at 48 hr and can last several days
    
  • Mild to moderate fever
    
• Systemic reaction:
  
  • Includes anaphylaxis
    
  • Can be fatal (usually owing to respiratory failure)
    
  • Respiratory:
    
    • Wheezing
      
    • Coughing
      
    • Stridor
      
    • Shortness of breath
      
    • Hoarseness
      
    • Angioedema
      
  • GI:
    
    • Nausea
      
    • Vomiting
      
    • Diarrhea
      
    • Abdominal pain
      
  • Cardiovascular:
    
    • Hypotension
      
    • Chest pain
      
    • Tachycardia
      
    • Shock
      
  • Other:
    
    • Urticaria
      
    • Pruritus
      
    • Flushing
      
  • Symptoms occur within 15–20 min and last ≤72 hr
    
• Toxic reaction:
  
  • Result of multiple stings and large doses of venom
    
  • Symptoms similar to anaphylaxis
    
• Unusual reactions:
  
  • Owing to unusual immune response
    
  • Vasculitis
    
  • Nephrosis
    
  • Serum sickness
    
  • Neuritis
    
  • Encephalitis
    
  • Reaction delayed (days to weeks after sting)
    

• History and physical exam key to diagnosis
  
• No radiologic or lab test will confirm hymenoptera envenomation or anaphylaxis
  

• CBC, electrolytes, BUN, creatinine, glucose, arterial blood gases (ABGs):
  
  • Not routine
    
  • Consider when significant systemic effects present
    

ECG:

• When significant systemic effects present in patients at risk for cardiovascular disease
  

• Insect bites sometimes cause pain; stings always cause pain.
  
• Cellulitis:
  
  • Difficult to distinguish between large local reactions and cellulitis
    
  • Infections of hymenoptera envenomations are rare and usually caused by wasp envenomations.
    
  • Local reaction can resemble periorbital cellulitis.
    
• Gout
  
• Soft tissue trauma
  
• Systemic/toxic reactions:
  
  • Pulmonary embolus
    
  • Anaphylaxis from different agent
    
  • Hyperventilatory syndrome/anxiety
    
  • Acute coronary syndrome