Winter 2015-2016 Newsletter
Welcome to the 2015-2016 winter edition of the Florida Chapter Division of AAEM (FLAAEM) newsletter. This newsletter is intended to bring members periodic updates on the practice of emergency medicine in our state and to highlight the benefits of membership. We at FLAAEM are working hard to represent our members’ interests! Let us know any issues you are experiencing practicing emergency medicine in the state of Florida so we can bring light to the situation. Email the board at firstname.lastname@example.org with any questions or concerns.
Vicki Norton, MD FAAEM, Vice President FLAAEM, Editor
Michael Dalley, DO FAAEM, Board of Directors FLAAEM, Communication Committee Co-Chair
In this Issue
Congratulations. You are receiving the FLAAEM newsletter, which means that you're committed to improving the Florida practice environment no matter how big the challenge seems. Like me, you are probably regularly questioning why it seems that Florida is the birthplace of every effort to degrade the rights and autonomy of EPs. Doesn't it sometimes feel like the rule is that "it only gets worse"?
It's easy to fall victim to "learned apathy.” It happens to mice when they receive an electrical shock no matter what path they take in a maze. Their response it to curl up into a ball and do nothing. Learned apathy is our biggest challenge. If we stop fighting, we will become participants in the erosion of our own specialty.
Fortunately, AAEM and FLAAEM are not apathetic, and the truth is that it doesn't always get worse. We are taking the fight to the perpetrators with innovations like the AAEM Physician Group (AAEM-PG) and the AAEM Foundation. FLAAEM recognizes that many EPs are falling victim to learned apathy and we are prepared to defend our specialty.
While I'm not suggesting anything quite as dramatic as a call to arms, I am asking two things of our members to fight the Florida learned apathy virus. First, if your rights as an emergency physician are challenged, tell us about it. Do not accept fear and intimidation as the new normal. Secondly, spread the word of AAEM and FLAAEM to your colleagues. With growing numbers our hammer will get bigger.
Thanks for your continued support and participation in FLAAEM.
David Rosenthal, MD FAAEM
FLAAEM Past President, David Farcy, MD FAAEM, is running for national AAEM President and has the full support and endorsement of our chapter division. In the past Dr. Farcy has been a leading advocate for emergency physicians in our state and has recently been serving at the national level on the AAEM Board of Directors. If you are heading to the 22nd Second Annual AAEM Scientific Assembly in Las Vegas on February 17-21, 2016, don’t forget to vote for Dave! Or vote online before the Scientific Assembly at http://www.aaem.org/about-aaem/leadership/elections.
Free Registration for FLAAEM Members!
Dress A Med - 20% Discount on scrubs/uniforms
FLAAEM is pleased to announce our latest partner in our member discount program. Dress A Med provides quality scrubs and medical uniforms. FLAAEM members receive a 20% discount sitewide.
Advanced Medical Certification - 35% Discount on online ACLS & PALS
FLAAEM has aligned with Advanced Medical Certification (AMC), the premier online certification and recertification course provider for health care professionals offering 100% online courses for certification and recertification in ACLS, PALS, BLS and CPR.
American Seminar Institute - 15% Discount on custom travel CME
American Seminar Institute (ASI) offers portable and accredited continuing education courses. You can take your individual course at home or anywhere in the world. Complete your continuing education when it fits into your schedule. Multiple specialty areas and topics are available.
FLAAEM Advocacy and Legislation reform
Free Western Journal of Emergency Medicine (WestJEM) subscription
The FLAAEM Board of Directors had their quarterly meeting in October and discussed the following topics:
- Expansion of membership benefits and recruitment.
- Sunny States social planning for the AAEM Scientific Assembly in Las Vegas in February.
- Fifth Annual Florida Chapter Division (FLAAEM) Scientific Assembly
- April 2-3, 2016 in Miami, FL at the Grand Beach Hotel Surfside
- Speaker Schedule
- Committee Updates: Communication, Government Affairs
- AAEM National Updates
Akash Mehta, DO
Fiona Azubuike, MD
Mt Sinai Medical Center, Miami Beach, FL
Chief Complaint: Rash
History of Present Illness: A 57 year old female with no significant past medical history presents with “red skin marks” which have been spreading for five days to now involve her entire body and face. She began taking amoxicillin five days ago for a “sore throat” and “malaise” which was prescribed by a clinic. She was seen in the emergency department 2 days ago, and was diagnosed as having an allergic reaction; she has been taking prednisone for 2 days. She denies any recent travel, or insect bites. On review of systems, the patient denies fever, eye discharge, headache, cough, dyspnea, current sore throat, nausea, joint pains, abdominal pain, hematuria, easy bruising. She affirms itching, facial swelling.
- Vital Signs: T: 98 F; P 77; RR 18; BP 111/66; 98% oxygen saturation on RA
- Constitutional: No acute distress.
- Head: Normocephalic. Mild bilateral facial swelling.
- Nose: No rash involvement of nares.
- Mouth/Throat: Sloughing of lips, no lesions in oropharynx.
- Eyes: Both conjunctiva injected.
- Neck: Supple. (-) Brudzinski's sign, Kernig’s sign.
- Cardiovascular: RRR. DP pulses 2+ bilaterally.
- Pulmonary/Chest: CTA bilaterally.
- Abdominal: Soft, nontender, nondistended.
- Genitourinary: Rash involves rectal and vaginal epithelium.
- Neurological: No focal deficits. Gait intact.
- Skin: Generalized flat erythematous lesions; mucosal involvement. (-) Nikolsky’s sign.
- CBC WITH DIFF
- WBC: 3.74
- RBC: 4.34
- Hemoglobin: 12.2
- Hematocrit: 38.0
- MCV: 87.6
- MCH: 28.1
- MCHC: 32.1
- RDW: 12.3
- Platelet Count: 200
- MPV: 10.8
- Neutrophils: 82.6
- Lymphocytes: 11.5
- Monocytes: 5.6
- Eosinophils: 0.3
- Basophils: 0.0
- BASIC METABOLIC PANEL
- Sodium: 138
- Potassium: 4.4
- Chloride: 104
- Bicarbonate: 27
- Glucose: 109
- BUN: 15
- Creatinine: 0.85
- Calcium: 9.3
What is the diagnosis judging by the clinical history and dermatological manifestation?
Toxic Epidermal Necrolysis
The photographs show flat, atypical, often target-like dusky red lesions with moderate confluence. There is mucosal involvement, and there is clearly involvement of greater than 30% of the body surface area. Nikolsky’s sign (exfoliation of epidermis with tactile pressure) was negative, although according to literature it is often present. In the emergency department (ED), there was stat consultation of dermatology and of a burn surgeon of the regional burn center. Thankfully, this patient was not yet showing signs of end-organ compromise, as she was hemodynamically stable throughout her time in the ED and the relevant laboratory studies were within normal limits. As recommended by the consultants, a foley catheter was placed to monitor urine output, and the patient received 2L of NS before transfer to the burn center.
Toxic epidermal necrolysis (TEN) and Stevens Johnson Syndrome (SJS) are severe adverse cutaneous reactions that affect approximately 1 or 2/1,000,000 annually. Most experts currently classify SJS as involving <10% of the body surface area, TEN as >30%, and 10-30% indicating a combination of the two. Extensive keratinocyte apoptosis causes the characteristic cutaneous manifestations described in our case; it should be noted that the lesions usually become more confluent as the disease progresses, as was occurring between the two visits in which I had examined the patient. Mucosal involvement and a positive Nikolsky’s sign are also almost always present.
There are two specific signs common to the early acute phase of SJS/TEN which helped lead us to our initial misdiagnosis: ocular involvement and a sore throat. Ocular involvement often presents as bilateral conjunctivitis and mild facial swelling, which often is misdiagnosed as part of an allergic reaction (as we had done.) Fever, sore throat, and malaise often are the initial symptoms of SJS, for which antibiotics are often prescribed (as the clinic had done).
Drugs (such as sulfonomides, penicillins, and several seizure-related medications) are assumed or identified as the main cause of SJS/TEN in most cases. However, Mycoplasma pneumoniae and Herpes simplex virus infections are well documented causes alongside rare cases in which the etiology remained unknown. Likely, TEN in this case can be attributed to the amoxicillin the patient was taking. However, because the patient admitted to malaise and a sore throat upon presentation to the clinic which had prescribed the amoxicillin, other causes cannot be ruled out.
- Consider SJS/TEN in your differential diagnosis for a cutaneous drug-related reaction, especially with ocular involvement.
- Consider SJS/TEN in your differential diagnosis for a patient with erythematous cutaneous findings in the setting of a sore throat, malaise or a recent upper respiratory infection.
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