DIAGNOSIS AND TREATMENT OF ATOPIC DERMATITIS RELIES ON UNDERSTANDING THE SKIN BARRIER

A patient presents with a rash. In emergency medicine we often recognize certain rashes at a glance, like urticaria or a viral exanthem. This does not fit any of those. The patient is scratching vigorously. Is this atopic dermatitis, commonly known as eczema?

 

Eczema might be the most common rash we see in the emergency department but its presentations are diverse so it is not always a “know it at a glance” diagnosis. We can get tricked. The etymology of eczema is “out boiling.” which describes that rash that is papulovesicular with erythema and weeping and crusting. A lot of rashes do that of course.

 

Atopic dermatitis is a special disease that arises from a defect in the epithelial connections between cells. When you understand that, you can diagnose it, and you can treat it.

 

The epithelial defect leads to microscopic “holes” in the skin. Water gets out, and irritants get in. Itching is dramatic.

 

Here is how you diagnose atopic dermatitis in the emergency department:

-Pruritus is a must

-The classic inflammatory rash of eczema (papulovesicular with erythema and weeping)

Allow for hyperkeratosis if the lesions are subacute or chronic

Allow for findings of excoriation

 

So far that hasn’t nailed down the specificity yet. Any inflammatory rash will do all that. Poison oak, for example will do the same thing.

 

Add in the specificity with:

dry skin by history or current presentation (defect in skin barrier)

distribution is flexural or hands by history or current presentation (areas of trauma and friction)

-history of atopic diseases or childhood onset

 

Now that you have the diagnosis, it is all about restoring hydration, and restoring the skin barrier. Have them take baths, hydrate the skin, and then lock it in with ointment. Teaching that will empower them to be less reliant on steroids.

 

TAKE HOME POINTS

-Suspect atopic dermatitis by severe itching and an inflammatory rash

-Localizes to areas of friction (hands or flexural areas)

-Dry skin prominent

-History of allergies or asthma

-Usually childhood onset

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HOW TO ACCESS THE HUMAN SIDE OF MEDICINE

A patient presents with respiratory distress and COPD. She is very dramatic in her gestures, very upset and emotional. The first time you saw her you had given her lorazepam and sent her home. It turns out she frequently gets that. You and your colleagues eventually set boundaries on that but she continues to present daily for respiratory distress. This case turns out to involve the deeper human side of medicine. How do you access that?

 

How do we not only know medicine but know the human condition? Read Shakespeare? Go to bedside medicine skills sessions with actors? Do an ED fellowship in emergency psychiatry?

 

I particularly enjoyed reading the articles by Frederick Platt from the University of Colorado. He was an internist who would put on workshops on difficult patients/encounters. In role playing, the clinician would learn to recognize strong affect, stop, and name the affect. “I sense you are feeling…upset…scared…angry…etc.” The patient then is invited to explain their fears and concerns.

 

Emotions, as the Latin root “motere” tells us, serve to “move” us. They motivate us and impel us to action. They are faster and more intuitive than verbal language. But they are not enough for us. We need to move the patient from nonverbal to verbal expression.

 

“I sense you are feeling scared.”

 

The patient starts crying. You ask why she is scared.

 

She is afraid of dying.

 

You then address that fundamental concern with her. You write “fear of death” as the diagnosis, knowing that future providers can at a glance review the primary diagnosis for each visit. As your colleagues and you empathetically address her concerns, the visits drop from daily to weekly to a couple times a year. She starts taking care of herself better and gets off the sedatives.

 

TAKE HOME POINTS

-if there is strong affect, stop, name it, and inquire about it

-transition the patient from nonverbal to verbal communication

-identify the concerns and needs behind each visit with a question like “what concerns you the most?”

-review the post on agenda setting for related suggestions

HOW TO GET PATIENTS TO TELL THE TRUTH ABOUT DRUGS

Patients often lie about drug use and that can interfere with care. Part of practicing emergency medicine is using skill in communication to get through those communication pitfalls.

 

To get patients to tell the truth on drug use, start with asking about past use. Then ask current.

 

Furthermore, sometimes it helps to ask the question specifically In my area, I tend not to ask “do you use drugs?” I ask “did you try amphetamines when you were younger?”

 

If they answer affirmatively then can expand to “when was the last time?”

 

If you have doubts about their answer, you can say “may I test your urine and confirm?” Their response is often revealing.

 

TAKE HOME POINTS

-Ask about past drug use first

-Then ask about recent drug use

-Ask permission for a drug screen

A TEMPLATE FOR DESCRIBING THE “ILL-APPEARING” INFANT

Templates do not just facilitate documentation but also can guide bedside observations. The person taking a history who uses OLD-CARTS might be reminded to ask a dimension of a symptom that otherwise would not have been elicited.

 

What does it mean to say a child is “well-appearing” or “ill-appearing?” I find the GCS (Glasgow Coma Scale) categories to be helpful:

 

Eyes – is the child attentive with the eyes

Motor – is the child appropriately active/reactive

Verbal – is the level of social interaction appropriate for age (eg comforted by the arms of the mother).

 

Using GCS can stimulate a more detailed description of what we mean when we describe an ill-appearing child.

 

TAKE HOME POINTS

-Use the categories of GCS to detail what it means for a child to be “ill-appearing.”

NONCONVULSIVE STATUS EPILEPTICUS

There are two scenarios where you might see non-convulsive status epilepticus (NCSE):

-Presentation of coma

-Failure to rouse after seemingly successful treatment of a seizure (one article said up to 20% of status epilepticus generates NCSE after resolution of the convulsion)

 

The gold standard is 48 hours of continuous EEG monitoring. Unfortunately at many EDs we rarely can get EEG monitoring at all. Thus we need to be mindful of some subtle clinical signs.

 

Clinical signs or triggers that might prompt you to consider non-convulsive status epilepticus:

-***history of epilepsy in someone in an unexplained coma***

-volatile vital signs

-dilated pupils

-twitching (disrobe patients. May especially notice this around the eyes, where it is easier to see)

 

TAKE HOME POINTS

-failure to rouse after seizure could indicate non-convulsive status epilepticus

-unexplained coma in someone with a history of epilepsy should trigger this possibility

-Disrobe the patient and look for subtle signs of twitching

-Consider autonomic signs – vital signs, pupils

AIRWAY VISUALIZATION – EXTERNAL “CEPHALIC” MANIPULATION

Here is a potential airway technique that may help with visualization: hold the laryngoscope in the left hand (the usual) but the right hand, instead of being at your side, is behind the patient’s head. You then move it around until you get the best view. Then you have an assistant hold the head in that spot.

 

A hospital in Southern California started doing that. The technique deserves some exploration. The work of Richard Levitan reminds us that the airway is most patent in the sniffing position. Extension does not really help but true sniffing position does. Sometimes you think you have enough and you need more.

 

I have not seen this technique studied but it probably deserves some attention.

 

TAKE HOME POINTS

-Consider external cephalic manipulation as an analogy to “external laryngeal manipulation” as a way of fine tuning the visualization during a tough intubation

INDIRECT LARYNGOSCOPY

A patient presents with severe sore throat. You wonder about epiglottitis. You know that using a mirror to look at the epiglottis is a great way to check this but are not confident in your skills. What do you need?

 

Dental mirror – they are cheap, have your ED stock them

 

Light – can use a headlamp, the kind that are sold in outdoor stores. Get one with a spot beam rather than a flood light. Nice to have regular AAA batteries instead of the medical ones with cords that are always getting lost or damaged

 

Relaxed patient – explain to them what you are doing and rehearse it once first

 

Anatomy – have them lean forward, chin out

 

View – wrap gauze around their tongue. Don’t pull it out but hold it so they don’t have to sustain muscle contraction to keep the tongue out

 

No gag – not sure topical anesthetics really work. Try to avoid hitting their pharynx with the mirror until you are ready to lift the uvula and look. Have the patient fix vision in the distance. Have them say “eeeeeee.” Have them do slow panting style shallow breathing.

 

No fog – hydrogen peroxide or hot water will help prevent fogging

 

You look and it is hard to see. That reminds us the final thing you need – practice!

 

TAKE HOME POINTS

-Indirect laryngoscopy is a complex hand-eye skill that you can learn

-Get the right supplies and start doing this now. It may really help you one day.

FINGER TEST FOR NECROTIZING FASCIITIS

A patient presents with a deep muscle abscess. Is this necrotizing fasciitis? All too often I see the deliberation focus on things like the laboratory score or the imaging. The role of those things are being debated but what is beyond debate is to have the bedside skills for recognizing necrotizing infections.

 

Childers in 2001 and 2002 described the finger test as a diagnostic intervention at the bedside. It does not get enough attention. The instructions are to make a 2 cm incision down to fascia. “…if the tissues dissect with minimal resistance, the finger test is positive”

 

Other signs:

-lack of bleeding

-grey necrotic tissue

-dishwater purulence

 

There is no reason ED physicians should not know this and perform it. We are already making incisions to check for abscess. Know the 4 surgical signs of necrotizing fasciitis.

 

TAKE HOME POINTS

The 4 surgical signs of necrotizing fasciitis are:

-lack of resistant to finger spread

-lack of bleeding

-grey necrotic tissue

-dishwater purulence

 

Childers BJ Necrotizing fasciitis: a fourteen-year retrospective study of 163 consecutive patients. Am Surg. 2002;68:109-16.

 

Andreasen TJ, Green SD, Childers BJ. Massive infectious soft-tissue injury: diagnosis and management of necrotizing fasciitis and purpura fulminans. Plast Reconstr Surg. 2001;107:1025-35.

BLADDER STIMULATION TECHNIQUES FOR NEWBORN CLEAN CATCH URINE COLLECTION

An infant presents with fever. The parents do not want a catheter placed in his penis. You want to check for urine infection. The resident suggests placing a bag. Are there any other options?

 

In 2013 Herreros-Fernendez described a technique of coaxing the child to urinate. She would tap the bladder at a rate of 100 taps per minute, and massage the low back. 86% of the time the child would urinate, with a median of 45 seconds. The population was strictly those less than 30 days of age, so it may not apply to older babies. The idea was inspired by bladder stimulation techniques used in adults with neurological diseases. There may be some element of a frontal lobe “release” reflex involved in the phenomenon.

 

The original study stacked the odds in their favor by feeding the babies, but follow-up studies all showed a greater than 50% success rate within 5 minutes. Thus, this technique is well worth trying in a low risk population.

 

Of note, the bladder tapping was 100 taps per minute. It is supposed to be gentle but the parents may quickly throw in the towel and ask for the catheter.

 

Take Home Points

-For the infant with a low suspicion of urinary tract infection, consider massage and bladder tapping to elicit a urination reflex

 

Herreros Fernández ML et al. A new technique for fast and safe collection of urine in newborns. Arch Dis Child. 2013;98:27-9.

LUNG AUSCULTATION: HEARING CRACKLES

You are seeing a patient with suspected pneumonia. Your attending hears crackles but you do not hear them. Later the radiograph shows pneumonia right where the attending heard crackles. What can you do to improve your pulmonary examination?

 

Sit up and take a deep breath might be bad advice?

 

Increase signal

Sensitivity for auscultation of crackles is increased in the supine position. Should you always listen supine? No. That is hard to do because anterior is less helpful and posterior requires you to squeeze the stethoscope behind their supine back. But be aware it is an option if you need to increase the sensitivity for the physical examination.

 

You can make crackles more easily discerned by varying your exam. If it sounded too quiet have them take a deeper breath.

 

Decrease noise

Should they always take a deep breath? No. That can increase other noise if they make upper respiratory noises. Have the patient take a “full and quiet” breath. That might be best for minimizing noise and maximizing signal.

 

Take Home Points:

-“Sit up and take a deep breath” is not the only way to do a lung examination

-Increase signal by auscultating the supine back

-Decrease noise by asking the patient to breathe deeply, but quietly