Rash

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My Notes:
From Dr Stan Inkes’s talk at Harbor:
  • numular exedma
    • can have superimposed infection
      • tx w/ bactrim
  • cat scratch fever
  • granuloma annulare – benign (circle ring shape), not fungal
  • superimposed infection on chicken pox -> bullous impetigo (varnious boarders, 
  • staph scalded skin syndrome
    • +nikoskly’s sign
    • no bacterial in lesons
    • clinda or bactrim/keflex
  • impetigo
    • honny  crusted
  • ash leaves 

Resources:

From ALiEM PV Card:

How to diagnosis a rash:

  1. Accurately describe the rash (eg. macule or nodule, vesicle or bulla)
  2. Quickly “profile” the rash to see if it fits any classic pattern by patient age, rash distribution, or presence of hypotension
  3. If you are still stumped, use an algorithm based on the rash type

Rash Descriptors

Lesion Single small diseased area
Rash Eruption of skin; more than single lesion
Macule Circumscribed area of change without elevation
Papule Solid raised lesion < 1 cm
Nodule Solid raised ≥ 1 cm
Plaque Circumscribed elevated confluence of papules ≥ 1 cm 
Pustule Circumscribed area containing pus
Vesicle Circumscribed fluid-filled area < 1 cm
Bulla Circumscribed fluid-filled area ≥ 1 cm 
Petechia Small red/brown macule ≤ 1 cm that does not blanch 

Quick Profiling of Rash

Patient age 0-5 yrs Meningococcemia
Kawasaki disease
Viral exanthema
>65 yrs Pemphigus vulgaris
Sepsis 
Menigococcemia 
TEN, SJS, TSS
Rash Diffuse erythema Staph SSS
Staph/strep TSS, 
Necrotizing fasciitis 
Mucosal lesions EM major, TEN, SJS, 
Pemphigus vulgaris
Petechiae/ purpura Menigococcemia
Necrotizing fasciitis 
Vasculitis
DIC
RMSF
Symptom Hypotension Meningococcemia
TSS
RMSF
TEN
SJS

Abbreviations:

  • TEN: Toxic epidermal necrolysis 
  • SJS: Stevens-Johnson syndrome 
  • TSS: Toxic shock syndrome 
  • SSS: Scalded skin syndrome
  • DIC: Disseminated intravascular coagulopathy 
  • RMSF: Rocky Mountain spotted fever 

Erythematous Rash

Maculopapular Rash

Petechial/ Purpuric Rash

Vesiculobullous Rash

References




  • from ALiEM
From UCSF Resident Handbook:

Maculopapular Rash

*Adapted from Murphy-Lavoie H and LeGros T, Emergency Medicine: A PeerReviewed Journal, 2010 

Cutaneous drug reaction

  • Common drugs: aminopenicillins, sulfas, cephalosporins, allopurinol, phenobarbitol, NSAIDs, quinolones, phenytoin, VPA, ACE inhibitors, thiazide diuretics, beta blockers, OCP, phenothiazines, corticosteroids
  • Mgmt: stop offending drug

Erythema multiforme (EM)

  • Associated with infection and drug exposures
  • Presentation
    • EM Minor: Pruritic target lesions on extremities self ltd 1-2wk
    • EM Major: Prodrome (URI, fever, malaise) then centripetally spreading non-pruritic target lesion rash with mucosal involvement.
  • Mgmt
    • EM minor: Topical steroids, outpt derm f/u
    • EM major: May need admission for supportive care, stop offending agent.
    • No role for systemic steroids

Lyme Disease

See CDC site: www.cdc.gov/lyme

  • Tick borne illness: Borrelia burgdorferi from Ixodes tick bite
  • Presentation
    • Erythema migrans (large target lesion) – spreads over days-weeks
    • Secondary rash, fever, meningitis, AV node block, migratory arthralgias, myalgia, Bell’s Palsy
  • Dx: Clinical symptoms or biopsy of tick bite; consider testing if equivocal
    • Serologic testing: Enzyme immunoassay (EIA) or immunofluorescence assay (IFA) then IgM/IgG western blot for confirmation of positive tests
  • Mgmt: Doxycycline100 mg PO bid
    • Erythema migrans: Treat for 10-14 days
    • Bells palsy, first degree heart block, arthritis: Treat for 21-28 days
  • Dispo: Usually outpatient management and follow up
  • Prophy after tick bite (Wormser GP et al, Clin Infect Dis 2006): Routine antibiotics not recommended, but consider doxycycline 200 mg PO x1 (Peds 4 mg/kg PO x1) if
    • Tick identified as adult or nypmhal I. scapularis attached for ≥36 h (based on engorgement with blood or known exposure time) AND
    • Prophy to be provided within 72 hours after tick removal AND
    • Local rate of infection with B. burgdorferi ≥20% (New England, mid-Atlantic states, Minnesota, Wisconsin) AND
    • Doxycycline not contraindicated (not pregnant, >8 yo, no allergies)

Pityriasis Rosea

  • No clear etiology, possibly viral
  • Presentation: “Christmas tree” pattern of scaly lesions with possible salmon-colored herald patch
  • Mgmt: Supportive with antihistamine, emollients

Scabies

  • Presentation: Pruritic, excoriated lesions commonly on hands in web spaces.
  • Dx: Clinical diagnosis, may see mites on skin scrapings with microscopy
  • Mgmt: Permethrin 5% topical cream. Apply to skin and leave 8-12h before washing off. May repeat in 1 week if mites reappear

Stevens-Johnson Syndrome (SJS)

  • Usually related to drug but also infections, malignancies
  • Presentation
    • Prodrome fever, myalgia, malaise rapid onset of rash (starts dorsa of hand)
    • Diffusely distributed bullous target lesions (+palm/sole/mucous membranes)
    • Toxic appearing
  • Mgmt: Stop offending agent, supportive care
  • Dispo: Usually admit to ICU

Viral Exanthem

  • Examples: Measles, rubella, fifths disease
  • Self-limited, supportive care

References

Erythematous Rash
  • Rash
    • petechial, purpurALiEMa that does NOT blanch is concerning for meninigits

*Adapted from Murphy-Lavoie H and LeGros T. Emergency Medicine: A Peer Reviewed Journal, 2010. 
**Nikolsky sign= lateral stroking of skin  separation of epidermis; SSS = Scalded Skin Syndrome; TEN = Toxic Epidermal Necrolysis; TSS = Toxic Shock Syndrome 

Anaphylaxis/anaphylactoid response

  • Cutaneous manifestations in 90% of cases
  • Presentation: Generalized urticaria, pruritus or flushing, swollen lips/tongue/uvula, laryngeal edema; CV (tachycardia, hypotension, shock), GI (abdominal cramps, vomiting, diarrhea)
  • Mgmt
    • Airway management, IVF
    • Remove offending agent if identified and possible
    • Epinephrine IM 1:1000 (1mg/mL) give 0.3-0.5mg IM q5-15min (Peds 0.01mg/kg IM q5-15min)
    • Epinephrine IV 1:10,000 (0.1mg/mL), 2-10 mcg/min titrated to BP (Peds 0.1-1mcg/kg/min titrate to BP)
    • Glucagon 1-2mg IV for adults on beta-blockers
    • Adjunctive: Benadryl 25-50mg IV, famotidine 20mg IV, albuterol, solumedrol120mg IV
  • Dispo: Observe 4-6 hours for rebound anaphylaxis and d/c with epi pen if improved/resolved; admit to ICU if no improvement or requiring epinephrine gtt

Kawasaki disease

  • Childhood vasculitis of unknown cause
  • Presentation: See diagnostic criteria below
  • Dx: Classic needs 4 of 5 diagnostic criteria + fever (“CRASH and Burn”); may have incomplete if <4
    • Conjunctival injection: Bilateral without exudate
    • Rash: Diffuse, polymorphous erythroderma
    • Adenopathy: Cervical LAD >15 mm diameter, usually unilateral, one, painful, non-purulent
    • Strawberry tongue, or diffuse oral/pharyngeal mucosal erythema, red/cracked lips
    • Hands and feet edema, erythema, or desquamation with convalescence
    • Burn: High fever ≥ 5 days
  • Mgmt
    • High dose ASA 80mg/kg/day PO in 4 divided doses initially
    • IVIG 2g/kg over 8-12h
  • Dispo: Admit to peds
  • Complications: Coronary artery aneurysm is serious complication

Scarlet fever

  • Associated with GAS pharyngitis
  • Presentation
    • Diffuse maculopapular “sandpaper” like eruption
    • Starts head and neck and spreads
    • Desquamation during convalescence
  • Mgmt
    • Same as streptococcal pharyngitis: PCN G IM 1.2 million U (25,000 U/kg) x1 or PCN VK 500 mg PO bid x10 days (12.5 mg/kg po qid x10 days)
  • Dispo: D/c home

Scromboid

  • Food-borne illness, classically from improperly managed fish e.g. tuna, mackerel, skip-jack, bonito. Due to elevated biogenic amines e.g. histamine
  • Presentation
    • Within 1h of ingestion: Flushing, erythematous rash, palpitations, tachycardia, sensation of warmth
    • Less often: HA, blurred vision, resp complaints.
  • Mgmt
    • Benadryl 25-50mg PO/IV
  • Dispo: D/c home, follow up w/ PMD/allergy to r/o fish allergy
  • Reportable condition! Need to fill out morbidity and mortality form

Staphylococcal Scalded Skin Syndrome (SSSS)

  • < 5yo highest risk, newborns commonly present at 3-7days old
  • Presentation: Abrupt fever, erythema of neck/axillae/groin with skin tender to palpation. No mucosal involvement
  • Mgmt
    • IV fluid resuscitation
    • Antistaphyloccocal antibiotic: nafcillin 50-200 mg/kg/day IV/IM div q6h (max 500 mg IV/IM q4-6h) or consider vancomycin 1 gram IV. May switch to dicloxacillin12.5-25 mg/kg/day PO div q6h (max 125-500 mg PO q6h)
    • Analgesia, local wound care
  • Dispo
    • Well appearing children >1yo with min slough outpt
    • Infants/toxic kids admit
    • Adults very rare but high mortality admit
    • Course: Heals 10-14 days without scarring

Toxic Epidermal Necrolysis (TEN)

  • TEN is in a spectrum of disease with erythema multiforme to SJS to TEN, with increasing toxicity
    • TEN: > 30% BSA involvement
    • SJS to TEN: 10-30% BSA involvement
  • Associated with sulfas (#1 cause), PCN, quinolone, antiepileptics, NSAIDs, allopurinol; also assoc with graft vs host rxn and blood product transfusion
  • Presentation
    • Sudden onset diffuse erythema with tender skin and sloughing
    • Face first and spreads down, massive skin sloughing, +mucosal involvement
    • Toxic appearing
  • Mgmt
    • Supportive care
    • D/c offending medicine
    • No steroids
    • Wound care: Don’t use sulfadiazine!! – sulfa containing
  • Dispo: ICU admission, burn unit if significant skin sloughing

Toxic Shock Syndrome (TSS)

  • Usually caused by Staph aureus producing exotoxin TSST-1
  • May also be caused by Streptococcal TSS (GAS)
  • Source can include abscess, tampon, nasal packing, wounds, postpartum
  • Presentation
    • Early macular rash, toxic appearing, shock, fever
    • Early rash can be quite pale – look for erythema of mucous membranes
    • Desquamation 1-2wk after illness onset
  • Dx: Criteria include fever, HoTN, erythematous macular rash, 3 organ system involvement and S. aureus infection
  • Mgmt
    • Supportive treatment: IVF, pressors
    • Remove source
    • Antibiotics: Clindamycin 600mg IV and Vancomycin 15mg/kg IV
    • Consider IVIG in severe cases
  • Dispo: admit to ICU

Vesiculobullous rash

*Adapted from Lavoie H and LeGros T, Emergency Medicine: A Peer ReviewedJournal, 2010 

Bullous Pemphigoid (D for deep blisters)

  • Better prognosis/less oral involvement than pemphigus vulgaris
  • Presentation
    • Chronic autoimmune cutaneous blistering in elderly (also infant)
  • Dx: Histopathology
  • Mgmt: Consult dermatology, may include topical/oral steroids, tetracycline, dapsone, immunosupressants
  • Dispo: Outpatient management

Contact Dermatitis

  • May result from a variety of irritants, commonly poison ivy/oak, nickel jewelry
  • Presentation
    • Papules/vesicles with erythematous base
    • Pruritic, watch out for secondary infection
  • Mgmt
    • Oral antihistamines
    • Topical steroid creams BID: hydrocortisone 1% cream or clobetasol 0.05% cream for more severe cases (avoid on face, can cause hypopigmentation)
    • Consider systemic steroids for severe cases with facial involvement, bullae or large BSA involvement. Should taper slowly

Hand-foot-and-mouth disease

  • Common in children
  • Most commonly caused by Coxsackie virus A16
  • Peak incidence Summer/Fall
  • Presentation
    • Oral lesions develop and then skin lesions including palms/soles
    • Can be asymptomatic or pruritic
    • Infants may have more diffuse distribution of lesions
  • Mgmt: Supportive care. Self limited, usually 3-6days. PO challenge and evaluate for dehydration in little kids

Herpes Zoster

  • Varicella-zoster virus reactivation
  • Presentation
    • Usually prodrome with pain/paresthesia prior to rash eruption
    • Painful, grouped, vesicular lesions in dermatomal distribution
    • Usually resolves over 2-3 weeks
    • Do not miss herpes opthalmicus (vesicles on tip of nose, check for corneal ulcers) or Ramsay Hunt syndrome (facial nerve involvement/Bells Palsy, vesicles on ear or TM, hearing loss)
  • Mgmt: Should start therapy within 48-72h
    • Valcyclovir 1 gram PO TID x 7days (or acyclovir 800mg 5x/day x 7-10 days) to prevent post-herpetic neuralgia
    • Prednisone 40-60 mg/day (controversial benefit to steroids, may improve symptoms)
    • Pain control: NSAIDS and narcotics
  • Dispo
    • Most patients managed outpatient
    • Admit patients with: Immunocompromised (transplant recipients in treatment for graft rejection, advanced AIDS with OIs), disseminated disease (involvement of multiple dermatomes, visceral organ), complications (e.g. Ramsay hunt, Zoster ophthalmicus, resistance to acyclovir)

Necrotizing fasciitis

  • Surgical emergency! Immediately consult Surgery if suspect this
  • Presentation
    • Severe spreading skin infection with possible crepitus, “dishwater” drainage
    • Pain may be out of proportion to examination
  • Mgmt
    • Surgery consult ASAP for debridement
    • Unasyn 3 grams IV or ampicillin 2 grams IV
    • Clindamycin 600 mg IV for toxin inhibition
    • ±Vancomycin 1 gram IV
  • Dispo: Admit to OR for debridement ICU

Pemphigoid Vulgaris (S for superficial blisters)

  • Rare, age 40-60, associated with myasthenia gravis and thymoma
  • Presentation
    • Generalized mucocutaneous autoimmune blistering disease
    • Triggers: Penicillamine, captopril, rifampin, stress
    • Painful, flaccid bullae, often oral involvement, +Nikolsky sign
  • Mgmt
    • Steroids and immunosuppressive therapy
  • Dispo: Admit if large areas of involvement

Smallpox

  • All lesions in same stage of development
  • If suspect this immediately isolate patient and notify public health department

Varicella

  • Adults at higher risk of varicella pneumonia and encephalitis
  • Presentation: Pruritic lesions, lesions are in different stages
  • Mgmt
    • Usually supportive care, symptomatic treatment
    • In pregnant patients consider treatment with acyclovir 800 mg PO 5x/day x7 days

Petechial rash

*Adapted from Murphy-Lavoie H and LeGros T, Emergency Medicine: A PeerReviewed Journal, 2010 

General tips

  • For petechiae/purpura not clearly explained by trauma or benign etiology consider CBC, coags, blood smear

Disseminated gonococcal infection

  • Presentation
    • Sparse, peripherally distributed vesicles
      • Associated urethritis/cervicitis/septic arthritis
  • Mgmt: Ceftriaxone 1 gram IV
  • Dispo: Admit

Henoch-Schonlein Purpura (HSP)

  • Autoimmune systemic vasculitis affecting skin, kidneys, GI tract
  • Mainly in school aged children
  • Presentation
    • Purpura (legs/buttocks/arms), abdominal pain, arthritis
    • Rash can initially be erythematous/macular/urticarial appearing
    • Hematuria 10-20%, vomiting/diarrhea/intussusceptions
  • Dx: Check UA – no Cr needed unless abnormalities on UA
  • Mgmt
    • Most self limited with supportive care only
    • Hydration/rest/analgesia and close outpt f/u
    • OK to give NSAIDs unless renal failure/sig GIB
    • Evidence unclear for steroids
  • Dispo
    • Home if pain controlled, no renal dysfxn/HTN, tolerating POs, no sig GIB, normal mental status
    • Generally weekly UA/BP measurements for 2months
    • Admit if above criteria not met

Idiopathic (immune) Thrombocytopenic Purpura (ITP)

  • May be associated with preceding viral infection
  • Presentation: Isolated thrombocytopenia with no clinically apparent condition
  • Mgmt
    • Transfusion if life threatening bleeding
    • Hematology consult for adjunctive treatment: Steroids, IVIG

Meningococcemia

  • Neisseria meningitides
  • Most common in young children and adolescents
  • Presentation
    • Preceding URI/flu-like symptoms
    • Initial erythematous maculopapular rash on wrists/ankles then spreads/petechial
    • Toxic appearing, febrile, AMS, shock
  • Mgmt
    • Ceftriaxone 2 gram IV (+ vancomycin 1 gram IV ± ampicillin 2 grams IV)
    • Steroids concurrent or prior to antibiotics
    • Supportive care
  • Prophy for contacts: Rifampin 600mg PO bid x 2 days or ciprofloxacin 500mg PO x 1
  • Dispo: Admit, droplet/contact precautions

Rocky Mountain Spotted Fever (RMSF)

  • Tick borne disease: Rickettsia rickettsii
  • Mostly April-September, mostly South Atlantic region and western south-central states
  • Presentation
    • Fever, rash, myalgia, headache – can range mild to life-threatening
    • Rash begins macular on wrist/ankle/forearm palm/sole/torso maculopapular petechial
    • 15% no rash (“spotless fever”)
    • May appear toxic, febrile
  • Mgmt
    • Doxycycline 100mg PO q12h x 7-10d for adults, consider doxy for peds >8yo, can give chloramphenicol 50-100 mg/kg/day div q6h (max 4 grams/day) for peds (not in neonates – gray baby syndrome) and pregnant (avoid if near term)
    • If unclear meningococcemia vs RMSF treat for both
  • Dispo: Can d/c with outpt f/u for mild cases, admit if sick appearing

Purpura fulminans

  • Associated with infection, pregnancy, massive trauma, end-stage malignancy, heptatic failure, snakebites, transfusion reactions
  • Presentation: Life-threatening disorder with fever, shock, subcutaneous hemorrhage, DIC, organ failure
  • Dx: Thrombocytopenia, schistocytes, elevated PT/PTT, decreased fibrinogen, elevated D-dimer
  • Mgmt
    • Treat underlying cause, folate, vitamin K, FFP, cryoprecipitate, blood products
    • Emergent Hematology consult
  • Dispo: admit to ICU

Thrombotic Thrombocytopenic Purpura (TTP)

  • Inhibition of ADAMTS13 enzyme by circulating antibodies unable to cleave von Willebrand factor multimers causing increased coagulation
  • Presentation
    • Clinical triad: Thrombocytopenia, hemolytic anemia, elevated LDH
    • Pentad: Fever, thrombocytopenia, hemolytic anemia, neurologic deficits, renal failure
  • Dx: Mostly normal coags and fibrin, +schistocytes/helmet cells on smear
  • Mgmt
    • Plasmapheresis, FFP to temporize
    • Emergent Hematology consultation
    • Do not give platelets unless life-threatening bleed and after consultation with Hematology; concern for precipitating additional thrombus
  • Dispo: Admit to facility with plasmapheresis

Heat Illness

General

  • Predisposing factors
    • Extremes of age: very young and elderly patients
    • Psychiatric patients
    • Patients with chronic diseases
    • Strenuous activity in heat in un-acclimatized patients

Heat Cramps

  • Brief, intermittent and severe muscle cramps typically in fatigued muscles after heavy work
  • Related to copious sweating and salt depletion after copious hypotonic fluid repletion
  • Not associated with rhabdomyolysis
  • Tx with PO or IV salt solutions and education

Heat Edema

  • Lower extremity edema occurring in un-acclimatized patients, especially elderly in sub/tropical areas, often associated with travel or more rigorous activities than usual
  • R/o other causes e.g. DVT, thrombophelbitis, lymphedema, CHF
  • Diuretics are of no utility and sx should resolve after a few days of acclimatization

Heat Syncope

  • Basically hypovolemia (due to sweating) and vasodilation (decreasing thoracic blood volumes) leading to syncope
  • Often in elderly
  • R/o other illness
  • If no other causes of syncope, reassure and educate about hydration

Prickly Heat (aka. Miliaria rubra/lichen tropicus/heat rash)

  • Acute inflammatory disorder of skin in hot/tropical climates
  • Caused by blockage of sweat glands by macerated stratum corneum and secondary staph infection
  • Acute phase: intensely pruritic vesicles on an erythematous base
    • Rash is usually confined to clothed areas and often area is anhdrotic
  • Profunda stage: 7-10 days later, keratin plug fills vesicles deeper obstruction of sweat gland and vesicles form in dermis. Can persist for weeks
    • Not pruritic and look similar to piloerection
  • Treatment
    • Chlorhexidine in light cream/lotion and antihistamines during acute phase
    • Salicylic acid 1% can be applied to affected areas
    • If diffuse, can try erythromycin
    • Prevention with loose fitting clothes and avoiding continuous sweating

Heat exhaustion/heat stroke

  • Heat exhaustion: Early spectrum of heat stroke
    • 2 major types, though usually presents as a mixed picture
      • Water depletion 2/2 inadequate PO intake with progressive hypovolemia
      • Salt depletion: Similar to heat cramps except systemic symptoms arise from hypotonic fluid intake
    • Clinical presentation
      • Vague malaise, fatigue, headache, n/v, muscle cramps
      • Core temperature may be normal or < 40 °C (104 °F)
      • Intact mental status, no coma or seizures
      • Dehydration: Tachycardia, orthostatic hypotension
      • Hyponatremia, hypochloremia and low urine sodium and chloride concentrations
  • Heat stroke: Associated with 30-80% mortality, hallmark is mental status change
    • Damage is a function of temperature and also exposure time
    • Failure of compensatory mechanisms of temperature regulation, leading to severe hyperthermia and multisystem tissue damage and organ dysfunction (always liver)
    • Neurologic dysfunction (e.g. AMS) is a key symptom requiring aggressive cooling
    • Types
      • Exertional: Young, healthy patients in setting of exercise. Assoc with diaphoresis, hypoglycemia, DIC, rhabdomyolysis, ARF, marked lactic acidosis and hypocalcemia
      • Classic: Elderly or sedentary patients with predisposing factors or meds, in setting of a heat wave. Assoc with anhidrosis, normoglycemia, mild ↑CPK, mild coagulopathy, oliguira, mild acidosis
  • Diagnosis
    • Exposure to heat stress, endogenous or exogenous
    • Signs of severe CNS dysfunction (ataxia, coma, seizures, delirium)
    • Severe hyperthermia (core temperature may be above 40.5 °C (105 °F), but may be lower if EMS cooled pt already, no strict cut-off)
    • Hot skin common, sweating CAN be present so can have heat stroke and be wet
    • Marked transaminitis
    • Differential diagnosis
      • Malignant Hyperthermia (MH)
      • Neuroleptic Malignant Syndrome (NMS)
      • Other drugs: MDMA, cocaine, serotonin syndrome, alcohol withdrawal, ASA
      • Seizures
      • Endocrine: Thyroid storm, pheochromocytoma, DKA
      • Sepsis and infection
      • In addition to common infections, consider encephalitis, meningitis, malaria, tetanus, typhoid
      • CNS hemorrhage
      • Treatment
        • Both heat exhaustion and heat stroke should be treated with cooling, with more aggressive interventions and monitoring for heat stroke
        • Mild illness (heat exhaustion)
          • Place in cool environment, assess volume status clinically, consider sending labs for electrolyte abnormalities
          • Rapid recovery usually follows fluid administration
          • Young or otherwise healthy patients can be treated as outpatients, otherwise admit
        • Severe illness (heat stroke)
          • IV, O2, monitor and invasive temperature monitor, labs
          • May consider antipyretics like APAP or NSAIDs in undifferentiated hyperthermia, but immediate cooling takes precedence in true heat stroke
          • Goal: Actively cool to 38-39 °C (100.4-102.2° F), then stop measures to avoid overshooting
          • Cooling methods: Evaporation preferred. May also consider ice packs to neck, axillae, groin, ice water immersion, cooling blankets. Consider cardiopulmonary bypass in severe or resistant coma
          • SFGH: Get a cooling blanket to place under the patient, then drape in a sheet soaked in room temperature water and use a floor drying fan propped up to blow air over the patient. Replace the damp sheet as needed by soaking with fresh water. Also place ice bags at axilla, groin, neck while protecting patient’s skin
        • Fluid resuscitation
          • Start at 1 liter and reassess. Pt is volume depleted, but once the systemic vasoconstriction resolves, they will be much less volume depleted.
          • Seizures: Treat with benzodiazepines to start as usual
          • Metabolic derangements: Watch for rhabdo, DIC, renal failure and electrolyte disorders and treat accordingly. Caution with rapid correction of hyponatremia (risk of central pontine myelinolysis)
          • Admit

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