What's Rash is that!

Talk for emergency nurses on recognising & managing common rashes!

1. What Rash is that? Is it Infectious? By Kane Guthrie

2. Learning P oints 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!

6. http://www.ausmed.com.au/blog/entry/how-to-describe-a-rash

7. http://www.ausmed.com.au/blog/entry/how-to-describe-a-rash

8. http://www.ausmed.com.au/blog/entry/how-to-describe-a-rash

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

15. http://scghed.com/

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

21. http://www.abc.net.au/news/2014-07-31/health-department-warns-of-surge-in-measles-cases-in-wa/5639558

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: 1 st 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

31. Non-Blanching Rashes!

32. 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

33. Meningitis Complications Abscess Cerebritis Deafness Cognitive impairment Hydrocephalus Death

34. Meningitis Management AB’s within 30mins of recognition Broad spectrum (Ceftriaxone) Immunocompromised add (Vancomycin) Haemodynamic support Dexamethasone 0.15mg/kg Q6 hourly

35. Case 5 http://scghed.com/2013/11/cme-141113-paediatric-rashes/

36. http://scghed.com/2013/11/cme-141113-paediatric-rashes/

37. 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

38. Case 6 28 male Hx epilepsy, on phenytoin Presents: Shocked Severe mouth ulcers Maculopapular rash

39. Stevens Johnson Syndrome Toxic Epidermal Necrosis SJS <10% BSA, TEN >30% BSA Dermatological emergency Causes: Drugs: anticonvulsants, NSAIDs, antiviral, allopurinal Malignancy: lymphoma Idiopathic Infectious

40. 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

41. Management Removing inciting cause Airway support Fluid replacements – follow burns protocol Wound care AB’s if infection Consider but controversial: IVIG, plasmapharesis, corticosteroids

42. 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

43. Henoch-Schonlein Purpura HSP- autoimmune, self limiting, IgA -mediated small vessel vasculitis Affects children 2-8 years old Diagnosis triad: Purpuric rash on lower limbs/buttock Joint pain/swelling Abdominal pain

44. Complications

45. 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

46. Case 8 18 male Eating kebab after night out Develops erythematous rash and SOB

47. Anaphylaxis IgE mediated hypersensitivity reaction Leads to profound: Histamine & serotonin release

48. Urticaria Vs Anaphylaxis Urticaria: hives, weals , nettle rash May occur alone or R/T allergic reaction Histamine release

49. 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

50. Diagnosis? Diagnosis? http://scghed.com/2013/11/cme-141113-paediatric-rashes/

51. 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

52. The Algorithms

53. Erythematous Rash http://bit.ly/1xf8rVH

54. Maculopapular Rash http://bit.ly/1xf8rVH

55. Petechial/Purpuric Rash http://bit.ly/1xf8rVH

56. Vesiculobullous Rash http://bit.ly/1xf8rVH

57. There’s an App!

58. 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