What's Rash is that!
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Talk for emergency nurses on recognising & managing common rashes!
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What's Rash is that!
- 1. What Rash is that? Is it Infectious? By Kane Guthrie
- 2. Learning Points • General assessment of rashes • Describing rashes • When to Isolate • Pearls & Pitfalls • Case studies
- 3. Rashes • Most are not evidence of serious illness • Frequently alarm patients/parents • Rashes are one of the top 20 presentations to ED • Often anxiety provoking to health care providers
- 4. Rashes! “Recognition is 99% of the problem; treatment/advice is usually simple”
- 5. Describing a Rash • It’s a little tricky • Keep it simple • Pattern recognition!
- 9. History Taking • When did it start? • How quickly did it progress? Pearl: • The more lethal – the more rapid progression!
- 10. History Taking • Has the rash changed over time? • Where did it start & progress to? • Is the lesion pruritic? – Allergic response!
- 11. History Taking • Recent travel? – In the last month! • PMHx: – Immunocompromised, asplenia, cancer, DM, ETOH • Occupation – Child care, student, military, aid workers • Medications
- 12. Physical Exam • Get them undressed! Check: • Oral cavity • Adenopathy • Hepatosplenomegaly • Genitals • Nails & fingers
- 13. Skin Exam • Characterise type of lesion • Shape of individual lesion • Arrangement of multiple lesions – Linear, annular, disseminated • Pattern of rash – Sun exposed areas, flexor/extensor surfaces
- 14. Case 1 • 10 year old girl • Coryza, conjunctivitis, cough, fever • Maculopapular rash, starts behind ears • Descends onto upper torso
- 16. Koplik’s Spots • Manifest 2-3 days before measles rash • Cluster lesions buccal mucosa http://en.wikipedia.org/wiki/Koplik%27s_spots
- 17. Measles • Acute viral disease • Incubation period 10-14 days • Highly contagious – airborne route – Airborne precautions needed! • Non-immune @ high risk!
- 18. Early Symptoms • Fever • Tiredness • Cough • Sore throat • Runny nose • Sore eyes • Photophobia http://www.nevdgp.org.au/info/murtagh/Childrens/measles.htm
- 19. The Rash • Symptoms usually worsen over 3-5 days • Blotchy rash begins on the head • Spreads to rest of body over 1-2days • Rash last 4-7 days
- 20. Measles Complications • Middle ear infection 7% of cases • Bacterial pneumonia 6% of cases • 1:1000 cases encephalitis occurs – Results in death, permanent disability
- 22. Measles Management • Vaccination is the best treatment • Supportive care • Treat complications with AB’s
- 23. Case 2 • 4 year male • C/O headache, fever, then rash develops • Explosion of lesions: 1st to face/scalp, then trunk & limbs • No rash soles or palms!
- 24. The Rash • Many papules • Become vesicles http://bit.ly/1zL2y5E
- 25. Chicken Pox • Acute generalised viral infection • Incubation period 11-17 days • Highly contagious • Transmission direct contact/airborne – Use airborne precautions
- 26. Shingles • Blistering rash – dermatome distribution • Increased age • Immunosupression • Stress http://1.usa.gov/1yBhN0c
- 27. Varicella Zoster Complications Chicken pox: • Pneumonia, congenital varicella, neonatal varicella Shingles: • Post-herpetic neuralgia, zoster keratitis, motor nerve paralysis
- 28. Varicella Management • Prevention –imunisation • Supportive care • Pneumonia – give AB’s Shingles: • Commence acyclovir ASAP – Limits post-herpetic neuralgia
- 29. Case 3 • 17 female • S/B GP c/o fever, headaches & muscle pain – Dx: viral illness – sent home to rest • 12 hours later develops peticial > purpuric rash • Arrives in ED shocked!
- 30. The Rash
- 33. Meningococcal Septicaemia • Acute Bacterial Infection • Mainly affects young children/adolescents • Transmission by direct contact Resp secretions – Droplet precautions – AB’s for staff if exposed to resp secretions • Incubation period 2-4 days
- 34. Meningitis Complications • Abscess • Cerebritis • Deafness • Cognitive impairment • Hydrocephalus • Death
- 35. Meningitis Management • AB’s within 30mins of recognition – Broad spectrum (Ceftriaxone) – Immunocompromised add (Vancomycin) • Haemodynamic support • Dexamethasone 0.15mg/kg Q6 hourly
- 38. Hand Foot & Mouth Disease • Coxsackie virus • Common in kids- can affect all age groups • Low grade fever, anorexia, sore mouth • Oral lesions develop – Vesicles/erythematous base – painful • Hand/foot lesions – red papules • Symptomatic care- mouth wash/analgesia
- 39. Case 6 • 28 male • Hx epilepsy, on phenytoin • Presents: Shocked • Severe mouth ulcers • Maculopapular rash
- 40. Stevens Johnson Syndrome Toxic Epidermal Necrosis • SJS <10% BSA, TEN >30% BSA • Dermatological emergency • Causes: – Drugs: anticonvulsants, NSAIDs, antiviral, allopurinal – Malignancy: lymphoma – Idiopathic – Infectious
- 41. Clinical Features • Prodrome: fever, URTI, malaise • Macular rash develops: – Starts centrally – spreads peripherally – May be painful – Nikolsky’s sign (skin separation via blisters) • Mucous membranes severely affected
- 42. Management • Removing inciting cause • Airway support • Fluid replacements – follow burns protocol • Wound care • AB’s if infection • Consider but controversial: – IVIG, plasmapharesis, corticosteroids
- 43. Case 7 • 4 year boy • Hx of ^ red spots to legs over past 6/7 • Now spread to legs, buttock • Not responding to cream • Systemically well
- 44. Henoch-Schonlein Purpura • HSP- autoimmune, self limiting, – IgA-mediated small vessel vasculitis • Affects children 2-8 years old Diagnosis triad: 1. Purpuric rash on lower limbs/buttock 2. Joint pain/swelling 3. Abdominal pain
- 46. Complications
- 47. Management • Check renal function • Give analgesia • Consider Prednisolone 1mg/kg - 2/52 • Abdo pain last <72 hours • Joint pain last <48 hours • Rash resolves 4-6 weeks
- 48. Case 8 • 18 male • Eating kebab after night out • Develops erythematous rash and SOB
- 49. Anaphylaxis • IgE mediated hypersensitivity reaction • Leads to profound: – Histamine & serotonin release
- 50. Urticaria Vs Anaphylaxis • Urticaria: hives, weals, nettle rash • May occur alone or R/T allergic reaction • Histamine release
- 51. Anaphylaxis Pearls • Forget about the rash! – Focus hypotension, bronchospasm • Give adrenaline – its only thing that works! – Adult 0.5mg IMI, Child 0.3mg IMI • Fluid bolus • Ranitidine • Steroid • D/C Epipen
- 53. Scabies • Skin infestation scabie mite • 4-6 wk incubation period • Not a reflection of poor hygiene! • General eruption: linear burrows, papules, pustules • Treatment: Permethrin 5% all family members http://www.wikem.org/wiki/File:ScabiesD08.JPG
- 54. The Algorithms
- 59. There’s an App!
- 61. Take Home Points • Pattern recognition is everything • Always take a good history • Isolate if unsure • Look for: – Fever, toxicity, distribution, specific signs • Management is generally simple
Notas do Editor
- Scabies