1. DR. FAISAL AL-SAWAFI EMERGENCY MEDICINE R1

11. Acute skin failure(ASF) is A state of total dysfunction of the skin resulting from different dermatological conditions. It constitutes a dermatological emergency and requires a multi-disciplinary, intensive care approach.

12. SO HEAT REGULATOR: loss of normal temperature control failure to prevent percutaneous loss of fluid, electrolytes and protein, with resulting imbalance, failure of the mechanical barrier to prevent penetration of foreign materials

25. Erythema multiforme (EM) Is an acute, self-limiting, mucocutaneous reaction pattern to many viral, bacterial, protozoal and fungal infections, tumors, drugs, autoimmune states and miscellaneous conditions. The most frequent cause is HSV infection followed by mycoplasma pneumoniae. Clinical spectrum of EM ranges from mild (erythema multiforme minor) to severe form (Steven-Johnson’s syndrome-TEN complex and TEN) Variable prodromal symptoms and a symmetrically distributed polymorphic rash classically with iris or target lesions seen on hands with a central vesicle, or erythema surrounded by a pale and then a red ring. The eruption in SJS(Severe EM) occurs preferentially periorificially or on mucocutaneous locations as painful erosions with thick adherent crusts.

29. Hemorrhagic erosions of the lips in EM, Severe eye-involvement in EM,

30. managment ABC ICU

31. ** The management of patients requires well-synchronized teamwork. ** In addition to experienced dermatologists, internists & well-trained, devoted nursing staff are needed for continuous monitoring of patients. The pillars in the management of such patients are **nursing care; **monitoring hemodynamic changes; **fluid, electrolyte balance and nutrition; **prevention of complication (e.g. sepsis); **prompt identification of risk factors; **& topical therapy .

32. Nursing care and general measures ** Patients can be managed in burn units or in a specialized ward . ** The environmental temperature should be maintained at 30°-32°C;alternatively, an infrared lamp can be used to reduce shivering & the associated energy loss. ** Use of air-fluidized beds & a burn-cage ensures patient comfort & easy handling.

33. Regular cleaning & removal of crusts from the oral & nasal cavities, & care of eyes, genitalia & perianal region has to be ensured. * bathing in lukewarm water (35°-38°C) is recommended * Introduction of an I.V line & urinary catheter or condom drainage are mandatory. * A nasogastric tube should be considered in the presence of severe mucosal involvement restricting oral intake or in severely ill patients. It helps in feeding , and assessing the gastric emptying . * An hourly record of the PR, RR , BP, & urine volume & osmolality is essential. * The body temp & gastric emptying should be recorded every 3 to 4 hours. * An accurate daily intake-output chart should be maintained.

35. Monitoring hemodynamic changes A urine output of 50-100 ml/hour and an osmolality lower than 1020 are indicative of adequate tissue perfusion. ** However, while assessing the adequacy of urine output in these patients, hyperglycemia has to be ruled out as it is commonly associated.

36. ** TEN is often compared with burn injury, the fluid requirement is 2/3rd to 3/4th of that of patients with burns covering the same area.

37. Topical management ** An oozy denuded skin should be managed conservatively. ** In patients with TEN, the detachable epidermis is preferably left in place. ** Topical agents (0.5% silver nitrate) ** Non-physiologic lipids (petrolatum jelly, lanolin) in vapor-permeable dressings (gauze) can be used as barrier repair agents. ** Use of physiologic lipids (component mixture of cholesterol, ceramide and free fatty acids in an optimized ratio of 3:1:1), accelerates the barrier repair. ** Moreover, use of these emollients prevents the skin surface from sticking to the bed or the apparel.

39. *** The poor prognostic factors in ASF are **older age **larger body surface area involvement **presence of severe neutropenia **early thrombocytopenia **high blood urea nitrogen level **a causative drug with long half life in drug-induced cases.

47. Bullous diseases Immunobullous diseases like pemphigus, pemphigoid, and hereditary mechanobullous disorders like epidermolysis bullosa can be disabling and even life-threatening in some cases Pemphigus vulgaris There are three main types of pemphigus- P foliaceous, (the blister is in the superficial granular layers), P vulgaris, (the blisters form just above the basal layer) and paraneoplastic pemphigus that occurs in association with malignancy Flaccid blisters are the primary lesions associated with painful erosions and Oral mucosal involvement.

48. Large erosive areas in a patient with pemphigus vulgaris

49. Generalized pustular psoriasis Is a rare but serious and even life-threatening form of psoriasis. Sheets of small, sterile yellowish pustules develop on an erythematous background and may rapidly spread . The onset is often acute. The patient is unwell, with fever and malaise, and requires hospital admission

53. STAPH. TSS

65. Staphylococcal Scalded Skin Syndrome A spectrum of superficial blistering skin disorders caused by the exfoliative toxins of some strains of Staphylococcus aureus . It is a syndrome of acute exfoliation of the skin typically following an erythematous cellulitis. Severity of SSSS varies from a few blisters localized to the site of infection to a severe exfoliation affecting almost the entire body.

79. Severe and acute urticaria caused by penicillin allergy

123. CLINICAL EVALUATION OF SKIN RASH POSSIBLE LIFE THREATINING FLUID FILLED SOLID PUSTULAR VESICO BULLOS NON ERYTHEMATOS ERYTHEMATOS

125. ERYTHEMATOUS DIFFUSE ERYTHEMATOUS PETECHIAL OR PURPURIC MACULO- PAPULAR

126. MACULOPAPULAR PERIPHERAL CENTRAL SKIN CONTACT YES NO VIRAL EXANTHEMA *BCUTANEOUS DRUG REACTION **LYME DISEASE **PITYRIASIS ROSEA *MENINGO- COCCAL *HAND FOOT MOUTH *RMSF *ERYTHEMA MULTIFORM *2NDRY SYPHILIS *ANTHRAX + SC - SC

127. Evaluating The Petechial Rash Petechial rash ➤ If the patient is ill-appearing, consider empiric treatment for meningococcemia and Rocky Mountain spotted fever ➤ Does the patient have any sick contacts? YES NO • Meningococcemia TRAVEL , INCIDENCE OF TICK BORN • Rubella YES NO • Epstein-Barr virus RMSV PALPABLE • Enterovirus DANGUE PURPURA FEVER YES NO • Gonococcemia VASCU- ITP LITIS TTP

128. DIFFUSE ERYTHEMATOUS *TSS *SSSS *KAWASAKI DISEASE